Long-term use of VA mental health services by older patients with substance use disorders

OBJECTIVE: The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system. METHODS: In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders. RESULTS: Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions. CONCLUSIONS: Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.     

Use of alcohol treatment and mental health services among adolescents with alcohol use disorders

OBJECTIVE: This study examined the use of and perceived need for alcohol treatment services among adolescents (aged 12 to 17 years) who received mental health services in the previous year compared with same-aged adolescents who did not receive such services. METHODS: Study data were drawn from the 2000 and 2001 National Household Surveys on Drug Abuse. The authors conducted logistic regression analyses to identify the characteristics associated with the receipt of and perceived need for alcohol services among adolescents with alcohol use disorders. RESULTS: Adolescents who received mental health services were much more likely than those who did not to meet criteria for alcohol use disorders in the previous year (10 percent compared with 4 percent). Among adolescents with alcohol use disorders, 15 percent of those who received mental health services used any alcohol services, compared with only 6 percent of those who did not receive mental health services. Of adolescents with alcohol use disorders who did not receive any alcohol services, only 3 percent reported a need for alcohol treatment. Among adolescents with alcohol use disorders who received mental health services, Hispanics were significantly less likely than whites to receive any alcohol services. CONCLUSIONS: These findings from a nationally representative sample of adolescents reveal a largely unrecognized and underserved population at risk. Factors related to the underutilization of alcohol services by adolescents with alcohol use disorders deserve greater research attention.     

Patterns of service use among persons with schizophrenia and other psychotic disorders

OBJECTIVE: This study assessed 12-month service use patterns among people with psychotic disorders and sought to identify determinants of service use. METHODS: As part of a large two-phase Australian study of psychotic disorders, structured interviews were conducted with a stratified random sample of adults who screened positive for psychosis. Demographic characteristics, social functioning, symptoms, mental health diagnoses, and use of psychiatric and nonpsychiatric services were assessed. Data were analyzed for 858 persons who had an ICD-10 diagnosis of a psychotic disorder and who had been hospitalized for less than six months during the previous year. RESULTS: People with psychotic disorders had high levels of use of health services, both in absolute terms and relative to people with nonpsychotic disorders. Those with psychotic disorders were estimated to have an average of one contact with health services per week. Use of psychiatric inpatient services was associated with parenthood, higher symptom levels, recent attempts at suicide or self-harm, personal disability, medication status, and frequency of alcohol consumption. Services provided by general practitioners (family physicians) were more likely to be obtained by older people, women, people with greater availability of friends, those with fewer negative symptoms, and those whose service needs were unmet by other sources. People who were high users of health services also reported having more contact with a range of non-health agencies. CONCLUSIONS: The predictors of service use accounted for small proportions of the variance in overall use of health services. The role of general practitioners in providing and monitoring treatment programs and other psychosocial interventions needs to be acknowledged and enhanced.     

Length of hospital stay and health services use of medical inpatients with comorbid noncognitive mental disorders: a review of the literature

We reviewed 23 studies on the association between noncognitive mental disorders and the use of general health care services by medical patients admitted to a general hospital. Only studies with a prospective design and with a correction for possible confounding factors were included. In most studies, only service use during index admission was observed, but eight studies included a longer observation period during follow-up after hospital discharge. The 15 studies that were restricted to service use during index admission showed mixed results: length of hospital stay was related to common mental disorders in some studies, but other studies did not find such an association. The eight studies that used a longer observation period showed findings that are more consistent. They demonstrated mainly that symptoms or complaints of depression are related to a higher resource use within general medical services.     

Perceptions of problems and needs for service among middle-aged and elderly outpatients with schizophrenia and related psychotic disorders

We examined the perceived problems and needs for services among 72 middle-aged and elderly outpatients with schizophrenia and related psychotic disorders. The survey questionnaire included 50 Likert scaled items involving everyday functioning skills, health, clinical symptoms, and social skills. Subjects assigned the highest priority to physical health and memory. Other areas of high priority were: social functioning, education about their own mental illness, and improvements in sleep and mood. Reducing frequency of psychiatric hospitalization, and drug or alcohol rehabilitation received low priority. Focused interventions targeting health-related and social issues are needed in older patients with schizophrenia.     

The effects of client-therapist match on service use and costs

The author explores the impact of ethnic matching between clients and their therapists or case managers on mental health service utilization and costs. Length of stay in outpatient and case management services of matched and unmatched clients was examined as well as the offset effect of this match on use of intensive and costly mental health services (inpatient, emergency, and skilled nursing facility). Matched clients had longer lengths of stay in outpatient but not case management services, and had significantly less utilization of all three intensive services. Annual cost savings to the system amounted to about $1,000 per matched client.     

Relationship of neuropsychological performance to functional status in nursing home residents and community-dwelling older adults.

OBJECTIVES: The authors examined the association between neuropsychological tests of executive functioning and episodic memory and functional disability in nursing home residents versus community-dwelling older adults. METHODS: The neuropsychological performance of 96 residents from the Jewish Home and Hospital, Bronx, NY and 192 gender- and age-matched older adults from residential communities in the New York metropolitan area was assessed in eight tasks (Word List Recall, Delayed Recall, Recognition, Boston Naming, Verbal Fluency, Trailmaking A and B, and Digit Symbol Substitution). Functional status was derived from the Clinical Dementia Rating scale (CDR) extended activities of daily living scores. Regression analyses were performed to test for differences in cross-sectional age-gradients for cognitive and functional status between nursing home residents and community-dwellers. Furthermore, regression analyses, controlling for age, gender, dementia status, and education, were performed to determine the association between neuropsychological performance and functional status, comparing domains of executive functioning and memory. RESULTS: Community-dwelling older adults showed age-related deficits both in overall cognitive status and functional disability, which were larger in nursing home residents. Executive functioning was associated with functional disability beyond the effects of age, gender, education, dementia status, residential status, overall cognitive status, memory, and cognitive speed. CONCLUSION: Executive functioning is associated with functional deficits in both community-dwelling older adults and nursing home residents. Measures of executive functioning may prove useful in intervention studies aimed at delaying institutionalization.     

Dementia in United States nursing homes: Descriptive epidemiology and implications for long-term residential care

Using data from the 1985 National Nursing Home Survey, the health and functioning of demented and non-demented nursing home residents are compared, and alternate forms of long-term residential care are identified. The 1985 National Nursing Home Survey is a cross-sectional investigation of residents in 1079 nursing and related care homes in the United States. Subjects for comparative analyses include 4622 residents age 65 and older from these facilities. Fifty-one percent had a diagnosis of dementia. Compared with non-demented residents, those with dementia had more impairments in physical and instrumental tasks of daily living, behavioral problems, and psychiatric symptoms, and fewer physical health comorbidities. Although statistically significant, many of the differences were small. Analyses indicate that there is considerable overlap in the health and functional status of nursing home residents with and without dementia. Both groups are heterogeneous in health and functioning and both have members without impairments. The traditional nursing home is one option for providing long-term residential care for these persons. Alternate residential care facilities such as board and care homes, sheltered housing and adult foster care are other options whose use is growing, especially for those not requiring continuous supervision and medical care.     

Analyses of the minimum data set: comparisons of nursing home residents with multiple sclerosis to other nursing home residents

This research compares nursing home residents with multiple sclerosis (MS) at admission to other nursing home residents using the minimum data set (MDS). These comparisons include sociodemographic characteristics and health status measures, as well as treatments and procedures received. We analysed 14,009 admission assessments in the MDS for residents with MS between June 22, 1998 and December 31, 2000. We also analysed 440,642 MDS admission assessments for all residents admitted to nursing homes during the year 2000, with any admission assessments for residents with MS excluded from this comparison group. Residents with MS were significantly younger at admission than other recently admitted residents. In addition, residents with MS tended to be significantly more physically disabled and also less cognitively impaired than other residents at admission, based on analyses of several measures of physical disability and cognitive performance. Nursing homes caring for residents with MS should provide services and programs, including mental health care, that address the needs of these younger, more physically disabled, and more cognitvely intact residents.     

Characteristics of older adults referred to a psychiatric emergency outreach service

Although older adults typically underutilize mental health services, problems associated with dementing illnesses, chronic medical illnesses, affective disorders, social isolation, and multiple medication use, among other phenomena, have increased referrals of the elderly to psychiatric emergency services. The present study reviewed characteristics of elderly adults referred to a psychiatric emergency outreach/screening service. Of all individuals for whom a referral was made, 24% were aged 60 or older. Among those older adults referred, 63% were seen by screening service personnel; 37% did not meet screening criteria or voluntarily sought mental health services. Diagnoses of individuals evaluated included dementia (27%), affective disorders (27%), schizophrenia (16%), psychosis (12%), alcohol abuse (7), and diagnosis deferred (11%). Findings highlight the limited options available for mental health care of the aged.     

Mental health services for nursing home residents: what will it cost?

The Nursing Home Reform Act of 1987 requires nursing homes to provide basic mental health services for all residents and to give active mental health treatment, a set of specialized mental health services, to those residents who are admitted with a serious mental illness. This article examines the potential size of the nursing home population who will require mental health services, its demographic composition, and the facilities in which these individuals reside using the Institutional Population Component of the National Medical Expenditure Survey. Estimates of the potential costs of providing monthly psychotherapy and pharmacological management to this population in nursing homes indicate that the mandate will have significant financial effects on nursing facilities. Conclusions about how the requirements for maintaining the mental and psychosocial well-being of nursing home residents may affect the future of nursing home care and mental health care are considered.     

Association between perceived social stigma against mental disorders and use of health services for psychological distress symptoms in the older adult population: validity of the STIG scale

Objectives: To document the reliability, construct and nomological validity of the perceived Social Stigmatisation (STIG) scale in the older adult population.

Design: Cross-sectional survey.

Setting: Primary medical health services clinics.

Participants: Probabilistic sample of older adults aged 65 years and over waiting for medical services in the general medical sector (n = 1765).

Measurements: Perceived social stigma against people with a mental health problem was measured using the STIG scale composed of seven indicators.

Results: A second-order measurement model of perceived social stigma fitted adequately the observed data. The reliability of the STIG scale was 0.83. According to our results, 39.6% of older adults had a significant level of perceived social stigma against people with a mental health problem. Results showed that the perception of social stigma against mental health problems was not significantly associated with a respondent gender and age. Results also showed that the perception of social stigma against the mental health problems was directly associated with the respondents’ need for improved mental health (b = ?0.10) and indirectly associated with their use of primary medical health services for psychological distress symptoms (b = ?0.07).

Conclusion: Results lead us to conclude that social stigma against mental disorders perceived by older adults may limit help-seeking behaviours and warrants greater public health and public policy attention. Also, results lead us to conclude that physicians should pay greater attention to their patients’ attitudes against mental disorders in order to identify possible hidden mental health problems.     

Analyses of nursing home residents with multiple sclerosis at admission and one year after admission

This research compares profiles of residents with multiple sclerosis (MS) at admission to the nursing facility with profiles of these same residents one year later using the Minimum Data Set (MDS) to determine how their health and care received changed after one year in the facility. We matched MDS admission assessments with their first annual assessment for 1309 residents with MS. These residents with MS demonstrated deterioration in cognitive performance, communication skills, motor performance and bladder/bowel continence after one year in the facility. However, the proportion of residents with urinary tract infections and the proportion of residents with pressure ulcers declined after one year. A significantly larger proportion of these MS residents had a diagnosis of depression one year after admission, with significantly increased use of antipsychotic and antidepressant medications but little and declining use of psychological therapy after one year in the facility. In addition, there was a significant decline after one year in the use of physical, occupational, and speech therapies. These longer stay residents with MS may benefit from support services directed toward mental health and increased use of physical, occupational and psychological therapies provided in the nursing facility.     

VA nursing home residents with substance use disorders: Mental health comorbidities,functioning, and problem behaviors

Objectives: This research addresses whether residents with substance use disorders (SUDs) in VA nursing homes (VANHs) are distinctive in terms of their demographic characteristics, medical and mental health comorbidities, functioning, and problem behaviors.

Methods: Residents over age 55 admitted to VANHs (n = 27,002) were identified in VA administrative files, and SUD and non-SUD residents were compared.

Results: Compared with other residents, the residents with SUDs (18% of admissions over age 55) were more likely to be younger, male, African-American, unmarried, have low income and a tobacco use disorder. Controlling for demographic factors and smoking, SUD residents were more likely to have mental health comorbidities (dementia, serious mental illness, depressive disorders, and post-traumatic stress disorder), as well as AIDS/hepatitis, pulmonary disease, gastro-intestinal disorders, and injuries. SUD residents were less likely to have cancer, diabetes, neurological disorders, heart failure, and renal failure. SUD residents were more independent in activities of daily living, such as mobility and toileting. They were more likely to engage in verbal disruption but not in other problem behaviors such as aggression. With demographic factors and comorbidities controlled, the functioning differences were diminished, and SUD and non-SUD residents did not differ in the levels of problem behaviors.

Discussion: VANH residents with SUDs have distinctive patterns of comorbidities and functioning. SUD appears to represent a separate risk factor for VANH admission. Residents with SUDs present challenges but may have good potential for positive discharge outcomes if their substance use problems and limited resources can be addressed.     

Analyses of nursing home residents with multiple sclerosis and depression using the Minimum Data Set

Depression is the most common psychiatric condition among people with multiple sclerosis (MS). A total of 14009 people with MS at admission to a nursing facility were analyzed using the Minimum Data Set and 36% also had depression. This study developed profiles of nursing home residents with MS who also had depression and compared them with other residents with MS. MS residents with depression were significantly more likely to be female and younger than other MS residents, with significant racial differences as well. MS residents with depression were significantly more likely than other MS residents to have a history of mental health conditions, exhibit mood indicators, and have unsettled relationships. Both groups of MS residents had high levels of physical disability, although MS residents with depression tended to be slightly less disabled. MS residents with depression were more likely than other MS residents to experience daily pain and more likely to have the diseases common to all residents with MS. This research found that most MS residents with depression did not receive mental health services, demonstrating that nursing facilities must improve the mental healthcare provided to residents with MS with depression.     

Alcohol problems among residents in old age homes in the city of Mannheim, Germany

OBJECTIVE: This study aims to determine the prevalence of alcohol problems among residents in old age homes, its demographic and clinical features, and its association with the risk of falling. METHOD: All residents (n = 1922) living in 20 randomly selected residential and nursing homes in the city of Mannheim, Germany, were included. Based on routine documentation, details of their sociodemographic features, medical diagnoses made upon admission, and current medication were compiled. The home staff filled out for each resident a standardised assessment sheet on activities of daily living-impairment (Barthel Index), behaviour problems, alcohol consumption, and frequency of falls. RESULTS: According to the diagnoses of the primary care physicians, 7.4% of the residents had mental and behavioural disorders due to alcohol (ICD-10: F10). Rates were particularly high among men, and younger and single or divorced residents. A high percentage of those with a diagnosis of alcohol abuse/dependence (41.1%) were transferred from mental hospitals. Home staff reported current alcohol abuse/dependence among 3.4% of all residents. The risk of falling was significantly elevated (Odds ratio: 2.65; p<0.01) among those with current alcohol problems. CONCLUSION: The results corroborate the findings from other studies wherein residents of old age homes constitute a group at risk of alcohol abuse and dependence. Alcohol problems were more the cause for, rather than the consequence of, home admission.     

Analyses of nursing home residents with Parkinson's disease using the minimum data set

This study profiles over 79,000 nursing home residents with Parkinson's disease (PD) at admission using the 'minimum data set'. Results show that residents with PD averaged 79.7 years of age at admission and 48.4% were male. They tended to be physically dependent, as well as cognitively impaired. More than one in three had fallen in the prior 30 days. There was a high prevalence of dementia and depression. Ninety percent of these residents did not receive active or passive range of motion care and less than 10% had been recently evaluated by a licensed mental health specialist. To enhance the quality of life for nursing home residents with PD, appropriate and adequate rehabilitative, mental health, and cognitive care need to be implemented.     

Mental health service use by older adults: the role of chronic pain.

OBJECTIVE: Mental health disorders commonly co-occur in patients with chronic pain, but little is known about the role of chronic pain in mental health service use. In this study, the authors explored the role of chronic pain in mental health service use by adults according to age group. METHOD: The authors conducted a cross-sectional analysis of survey data from the second wave of the Health Care for Communities telephone survey collected in 2000-2001. Participants consisted of U.S. civilian adults (N = 6629) from randomly selected U.S. households. Common mental disorders were assessed using the short-form versions of the World Health Organization's Composite International Diagnostic Interview. Chronic pain conditions and mental health services received were identified by self-report. Physical and mental functioning was assessed using the Short Form-12. RESULTS: Adults older than age 60 had higher rates of chronic pain and lower rates of mental health service use compared with those aged 18-60 years. In multiple logistic regression models, an interaction effect was found between age and chronic pain (odds ratio: 3.0 [1.1-8.0]) with chronic pain significantly increasing the odds of any mental health care in the past year in adults older than 60 years of age. CONCLUSIONS: Chronic pain increases the likelihood of mental health service use among older adults. Chronic pain may facilitate the presentation of distress in medical settings for these adults.     

Lifetime use of mental health and substance abuse treatment services by incarcerated women felons

OBJECTIVE: This study examined the lifetime use of alcohol, drug, and mental health treatment services by recently incarcerated women prison inmates. METHODS: A total of 805 women entering a North Carolina prison for new felony charges in 1991 and 1992 were interviewed in person shortly after incarceration. The women were assessed for psychiatric disorders and lifetime use of substance abuse and mental health treatment services. Rates of service use were analyzed by inmate characteristics and were compared with rates for a sample of women in the community in North Carolina. RESULTS: The majority of women inmates reported a history of using substance abuse services or mental health services or both. Those with psychiatric disorders and prison recidivists were the most likely to have used such services. Rates of service use were substantially higher for the inmates than for the women in the community, even when the effects of having a psychiatric or substance use disorder were controlled for. CONCLUSIONS: Many of the incarcerated women in the study met lifetime criteria for alcohol, drug, and mental health disorders that were significantly related to their use of substance abuse and mental health treatment services. The majority of the inmates met criteria for a current disorder despite past treatment. Further research is needed to help in developing programs to reduce women inmates' alcohol, drug, and mental health problems.     

Differences in the use of health services among people with and without epilepsy in the United Kingdom: socio-economic and disease-specific determinants

We aim to examine the socio-economic, demographic and disease-specific determinants in the use of health services by patients with epilepsy, compared to people without epilepsy. We used data from the fourth national survey of morbidity in general practice, carried out in 1991–1992. Overall mean annual number of consultations with general practitioners, home visits and referrals to secondary care per person were calculated for people with epilepsy, stratified by age, sex and socio-economic status. The proportion of patients consulting for certain diseases or disease groups were also calculated for patients with epilepsy. Results were compared to these in people without epilepsy, and rate ratios were calculated. Patients with epilepsy consulted twice as often, required three to four times more home visits, and were referred to secondary care three times more often than people without epilepsy, irrespective of age, sex and social class. Among patients with epilepsy, consultation rates and home visits were higher in females, older people and people from the manual social classes. A higher proportion of patients with epilepsy consulted for neoplasms, haematological and mental health disorders, dementia, stroke and gastrointestinal bleeding. Older age and low social class were less strongly associated with health service utilisation than in people without epilepsy, indicating that people with epilepsy lose much of the protective effect of young age and high social class on health. Factors contributing to the higher utilisation of health services in people with epilepsy need to be studied further and their effects taken into account in the organisation of health services for people with epilepsy.