Medical clinic characteristics and access to behavioral health services for persons with HIV

OBJECTIVE: Many persons with HIV do not receive needed behavioral health services. This study examined the impact of medical clinic characteristics on access to mental health and substance abuse care for persons with HIV. METHODS: This was a longitudinal survey of patients and clinic directors participating in the HIV Cost and Services Utilization Study, a national probability sample of persons in care for HIV between 1996 and 1998 (N=2,031). Primary outcomes were receipt of outpatient mental health specialist care, outpatient substance abuse care, and abstinence from substance use in the past 30 days. RESULTS: After adjustment for patient characteristics, the likelihood of care by a mental health specialist was higher for patients in HIV specialty clinics (odds ratio [OR]=2.1, 95% confidence interval [CI]=1.2-3.5) and clinics with a combination of on-site case management and affiliated mental health care (OR=2.3, CI 1.3-4.4, for off-site affiliated care; OR=2.1, CI=1.2-3.7, for on-site care). Outpatient substance abuse care also was more likely for patients in clinics with on-site case management and affiliated substance abuse care (OR=4.3, CI=1.5-12.2, for off-site affiliated care; OR=3.2, CI=1.3-8.0, for on-site care). In a subgroup of persons reporting active substance use, care in clinics with on-site case management predicted 30-day abstinence from substances at follow-up (OR=1.7, CI=1.1-2.5). CONCLUSIONS: The organizational structure of medical clinics can have an important effect on use of mental health and substance abuse specialist care.     

Patterns of health care costs associated with depression and substance abuse in a national sample

OBJECTIVE: The associations between self-reported depressive and substance use disorders and estimated health care costs were examined in a representative national sample. METHODS: Data were from the 1994 National Health Interview Survey (N=77,183). Respondents who reported depressive symptoms or major depression (depressive syndromes) or a substance abuse disorder in the past year were compared with respondents who did not report these conditions. The mean number of inpatient days and outpatient visits in both the general medical and the specialty mental health settings were determined, and costs per individual were calculated based on mean costs of such care in each respondent's geographic region. Multivariate models were constructed to calculate mean costs, controlling for demographic variables, insurance coverage, and physical health status. RESULTS: Individuals with self-reported depressive syndromes or substance abuse had mean health care costs that were $1,766 higher than costs for individuals without these conditions. Depressive syndromes were associated with increases in both inpatient and outpatient costs. However, substance abuse was almost exclusively associated with increased inpatient expenditures rather than outpatient costs. The magnitude of increased costs associated with mental disorders was substantially larger for patients in fee-for-service plans than for those in health maintenance organizations. Only 14.3 percent of visits made by individuals reporting depressive syndromes or substance abuse were made to specialty health providers (psychiatrists, psychologists, and social workers). CONCLUSIONS: Health care costs of people with self-reported mental illness varied significantly across diagnoses and systems of care. It is crucial that researchers estimating increased costs associated with mental illness account for both diagnostic and system factors that can influence the estimates.     

Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use

OBJECTIVE: The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. METHOD: This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N=70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). RESULTS: Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. CONCLUSIONS: Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.     

Managed care organizational complexity and access to high-quality mental health services: perspective of U.S. primary care physicians

This analysis addresses the relationship between perceived access to high-quality specialty mental health and medical services and 2 aspects of managed care organizational complexity at the practice level: 1) gatekeeper requirements for specialty services, and 2) managing multiple contracts. Cross-sectional analysis of a national telephone survey of 7,197 primary care physicians (PCPs) was performed. Access was defined as high-quality specialty services being always or almost always available to the PCP's patients when medically necessary. PCPs rated access to high-quality outpatient specialty mental health services as much lower than that of specialty medical services (28%; 95% confidence interval [CI], 27-29 versus 81%; 95% CI, 80-82). After adjustment for physician, practice, and managed care factors (multiple logistic regression analysis), perceived access to high-quality outpatient mental health services was lowest for practices with the largest number of managed care contracts and when a physician's practice was a "mixed model" with regard to the gatekeeper function. Perceived access to high-quality specialty medical services was not as strongly associated with these practice characteristics. PCPs who interact with a large number of managed care plans and different administrative models may have the most difficulty in obtaining high-quality mental health services for their patients.     

Substance Abuse Providers' Assessment of the Massachusetts Behavioral Health Program: Year 6

Substance abuse providers surveyed after Year 6 of the Massachusetts Behavioral Health Plan reported better treatment outcomes and access than in previous years. The Massachusetts Behavioral Health Partnership's clinical practices helped to improve quality of care. Its review process was highly rated. Coordination of substance abuse and mental health services was favorable, but was unfavorable with primary care. Staffing and organizational changes are described. Comparisons of outpatient and detoxification providers' responses with previous mental health and substance abuse surveys are made.     

Mental Health and Substance Abuse Services to Parents of Children Involved with Child Welfare: A Study of Racial and Ethnic Differences for American Indian Parents

American Indian (AI) parents of children involved with child welfare were compared to White, Black and Hispanic parents on mental health and substance abuse problems and access to treatment. Data came from the National Study of Child and Adolescent Well-Being, a longitudinal study of a nationally representative sample of children aged 0–14 years involved with child welfare. Weighted statistics provided population estimates, and multivariate logistic regression was used to predict the likelihood of caregivers receiving mental health or substance abuse services. There were significant disparities in the likelihood of receiving mental health, but not substance abuse, services. Unmet need for mental health and substance abuse treatment characterized all parents in this study. AI parents fared the worst in obtaining mental health treatment. Parents of children at home and of older children were less likely to access mental health or substance abuse treatment.     

A national survey of care for persons with co-occurring mental and substance use disorders

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.     

Swept away: use of general medical and mental health services among veterans displaced by Hurricane Katrina

OBJECTIVE: This study examined national patterns of outpatient service use by veterans from regions affected by Hurricane Katrina. METHODS: Analyses tracked use of general medical and mental/substance use services in September and October through December 2005 in New Orleans and Biloxi-Gulfport compared to a cohort receiving care during the same months in the previous 2 years. RESULTS: In adjusted models, veterans from New Orleans and Biloxi-Gulfport were, respectively, 73% and 41% less likely in September 2005 to use any outpatient services as were cohorts from 2003-2004. Particularly in New Orleans, the relative decline in service use was substantially greater for specialty mental health and substance use services than for general medical services. CONCLUSIONS: Although many veterans were able to obtain care after Hurricane Katrina, there was a substantial disruption in delivery of Veterans Administration services, with disproportionate declines in mental health and substance use care.     

Medicaid eligibility and access to mental health services among adolescents in substance abuse treatment

OBJECTIVE: The co-occurrence of a mental disorder is common among adolescents who present for substance abuse treatment. This study was conducted to determine whether Medicaid eligibility was associated with greater use of mental health services. METHODS: The study used administrative data for 25,813 adolescents in Oregon. Propensity score analysis was used to assess the likelihood that the adolescents would use mental health services, with group differences and mental health need controlled for. RESULTS: Medicaid-eligible youths were nearly five times as likely to receive mental health services in the year they entered substance abuse treatment compared with non-Medicaid-eligible youths. In both groups, there was evidence of racial disparities as well as factors such as foster care that may facilitate access. CONCLUSIONS: The fact that Medicaid-eligible youths have greater access to mental health services should be considered in both state policies and research design. States considering ways to better serve adolescents with co-occurring disorders would do well to examine ways to promote Medicaid enrollment or expand eligibility.     

A Comparison of Treatment Outcomes Among Chronically Homelessness Adults Receiving Comprehensive Housing and Health Care Services Versus Usual Local Care

Service use and 2-year treatment outcomes were compared between chronically homelessness clients receiving comprehensive housing and healthcare services through the federal Collaborative Initiative on Chronic Homelessness (CICH) program (n = 281) a sample of similarly chronically homeless individuals receiving usual care (n = 104) in the same 5 communities. CICH clients were housed an average of 23 of 90 days (52%) more than comparison group subjects averaging over all assessments over a 2-year follow-up period. CICH clients were significantly more likely to report having a usual mental health/substance abuse treater (55% vs. 23%) or a primary case manager (26% vs. 9%) and to receive community case management visits (64% vs. 14%). They reported receiving more outpatient visits for medical (2.3 vs. 1.7), mental health (2.8 vs. 1.0), substance abuse treatment (6.4 vs. 3.6), and all healthcare services (11.6 vs. 6.1) than comparison subjects. Total quarterly healthcare costs were significantly higher for CICH clients than comparison subjects (4,544 vs.4,544 vs. 3,326) due to increased use of outpatient mental health and substance abuse services. Although CICH clients were also more likely to receive public assistance income (80% vs. 75%), and to have a mental health/substance provider at all, they expressed slightly less satisfaction with their primary mental health/substance abuse provider (satisfaction score of 5.0 vs. 5.4). No significant differences were found between the groups on measures of substance use, community adjustment, or health status. These findings suggest that access to a well funded, comprehensive array of permanent housing, intensive case management, and healthcare services is associated with improved housing outcomes, but not substance use, health status or community adjustment outcomes, among chronically homeless adults.     

Provision of Mental Health Services in South African Substance Abuse Treatment Facilities

To date, South African research has not examined mental health service provision in substance abuse treatment facilities, even though these services improve client retention and treatment outcomes. To describe the extent to which substance abuse treatment facilities in Gauteng and KwaZulu-Natal provinces provide clients with mental health services during the course of treatment and to compare mental health service provision in these settings by type of facility and staff composition. Cross-sectional audits of substance abuse treatment facilities were conducted in Gauteng and KwaZulu-Natal provinces. Data were collected using the Treatment Services Audit Questionnaire. A response rate of 84% was obtained. Few treatment facilities provide clients with access to mental health services. Inpatient facilities are more likely than outpatient facilities to provide clients with access to mental health services. Facilities with for-profit ownership status are more likely than facilities with non-profit status to provide access to mental health care. Based on the above findings, a number of recommendations are made to increase the provision of mental health services during the course of substance abuse treatment.     

Use of mental health care and substance abuse treatment among adults with co-occurring disorders

OBJECTIVES: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. METHODS: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. RESULTS: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use disorder with one or more mental health symptoms and without serious mental illness, 1,872 had a substance use disorder with serious mental illness, 13,759 had one or more mental health symptoms only, and 7,530 had a serious mental illness only. A substantial proportion of adults with comorbid mental health problems and a substance use disorder did not receive any treatment (46 percent of those with serious mental illness and 65 percent of those with one or more mental health symptoms). Co-occurring substance use disorder was not associated with increased use of mental health care. The likelihood of receiving any substance abuse treatment increased with the presence and severity of mental health problems. Across all five groups, use of mental health care was more common than use of substance abuse treatment. Less than one-third of patients with comorbid mental health problems and a substance use disorder who used mental health care also received substance abuse treatment. CONCLUSIONS: The large proportion of untreated individuals with mental and substance use disorders reinforces existing concerns about barriers to beneficial treatment. Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted.     

Shifting to outpatient care? Mental health care use and cost under private insurance.

OBJECTIVE: Concern over rising health care costs has put pressure on providers to reduce costs, purportedly by reducing inpatient care and increasing outpatient care. METHOD: Inpatient and outpatient claims were analyzed for adult users of mental health services (180,000/year on average) from a national study group of 3.9 million privately insured individuals per year from 1993 to 1995. Costs and treatment days per patient were compared across diagnostic groups and stratified by whether patients were hospitalized. RESULTS: Inpatient mental health costs fell $2,507 (30.4%) over the period, driven primarily by decreases in hospital days per patient per year (19.9%), with smaller changes in the proportion of enrollees who received inpatient care (increase of 0.8%) and a decrease in per diem costs (9.1%). Outpatient mental health costs also declined over the period, falling 13.6% for patients also using inpatient services and 14.6% for patients receiving only outpatient care. Patients whose primary diagnosis was mild to moderate depression saw the largest decreases in inpatient cost per patient (42.8%); those diagnosed with schizophrenia experienced the smallest decrease (23.5%). For patients using outpatient services only, those diagnosed with substance abuse experienced the largest decrease in costs (23.5%); those diagnosed with schizophrenia experienced the smallest decrease (8.6%). CONCLUSIONS: Substantial cost reductions for mental health services are primarily a result of reductions in inpatient and outpatient treatment days. Declines in inpatient service use were not accompanied by increases in outpatient service use, even for severely ill patients requiring hospitalization. Managed care has not caused a shift in the pattern of care but an overall reduction of care.     

General medical and specialty mental health service use for major depression

OBJECTIVE: While major depression is common, many depressed persons receive, at best, inadequate treatment. A first step in remedying inadequate detection and treatment of major depression requires understanding the pathways into treatment-from situations of no care, to disease recognition, to referral and appropriate treatment-as well as identifying factors associated with movement between these several stages. METHODS: Using the Epidemiologic Catchment Area sample, we identified factors associated with treatment in the general medical or mental health specialist section, or no treatment in a subsample of individuals with current major depression. RESULTS: Strikingly, one-fourth of the sample received no services, over half received care in the general medical sector, and only one-fifth accessed a mental health specialist. Among those receiving any health services (general or mental), men and respondents reporting suicidal symptoms were at risk of receiving no care, while perceived poor health and a cluster of core depressive symptoms were associated with increased odds of service use (general or mental). Among respondents receiving general medical services, perceived poor health, core depressive symptoms, a history of depression, and comorbid mental conditions increased the odds of treatment in the specialty mental health sector. CONCLUSIONS: The findings emphasize the need for public health initiatives to 1) improve detection and movement into treatment among those at risk of receiving no care; and 2) insure that, once within the health care system, the processes of primary care treatment and specialty referrals conform to evidence-based treatment guidelines.     

American Indians with HIV/AIDS: health and social service needs, barriers to care, and satisfaction with services among a Western tribe

This study investigated the health care and social service needs, barriers to care and satisfaction with services among American Indians with HIV/AIDS in a western tribe. Individual interviews were conducted with 28 respondents, which constituted nearly the entire population obtaining HIV/AIDS medical services from the IHS in the target area. The survey found that expressed need for services in this frontier rural area were lower than urban counterparts, but that access to needed services was lower. Common unmet medical needs include mental health services, eye and dental care, traditional Native medicine, and substance abuse treatment. Common unmet social service needs include housing assistance, help obtaining food and clothing, and transportation. Limited access to essential services impedes the ability of American Indians with HIV/AIDS to maintain effective medical regimens.     

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.     

Adolescents with Substance Diagnoses in an HMO: Factors Associated with Medical Provider Referrals to Substance Abuse and Mental Health Treatment

This study examines the factors related to referrals of adolescents with substance use disorders to substance abuse or mental health treatment by their medical providers. Administrative and chart review data from the membership of a large private health maintenance organization (HMO) were collected from a probability sample of 400 adolescents, ages 13-18, who were diagnosed with a substance use disorder in 1999. Logistic regression analyses examined referral to substance abuse treatment and referral to mental health treatment in the aggregate and stratified by gender. Documented use of both alcohol and another illicit drug, and legal problems increased likelihood of referral to substance abuse and mental health treatment, whereas diagnoses of alcohol and marijuana use disorders decreased likelihood of referral to substance abuse treatment. Mental health diagnoses played a limited role in both types of referrals, although specific psychosocial problems were associated with increased likelihood of referrals. Treatment history and location of first mention of problem were significant predictors of referral. There were no gender differences in referral rates to either substance abuse or mental health treatment; however predictors of referral differed by gender. These findings extend our knowledge about factors that influence clinicians' treatment referrals of adolescents with substance abuse diagnoses and have implications for influencing clinician referral behavior within health plans.     

Mental illness and use of home care nationally in the U.S. Department of Veterans Affairs.

OBJECTIVE: To determine whether patients with mental health diagnoses are more likely to utilize home-based primary care (HBPC), and to identify characteristics associated with HBPC admission among elderly and nonelderly veterans, specifically. METHODS: Patients receiving treatment during fiscal year (FY) 2003 and having no evidence of home care utilization during FY2002 were followed through FY2005 using administrative claims data of the Veterans Health Administration of the U.S. Department of Veterans Affairs (VA). Participants were 4,411,677 VA patients with no prior HBPC use. Cox proportional hazard models were developed to identify correlates of HBPC use. RESULTS: Of VA patients with no prior use of HBPC, 24.2% received a mental health diagnosis, of whom 1.5% eventually used HBPC. Two in five new HBPC admissions were diagnosed with mental illness. Patients diagnosed with dementia were 66% more likely to be admitted. Patients diagnosed with nonschizophrenia psychoses (hazard ratio [HR]: 1.30), miscellaneous affective disorders (HR: 1.22), and schizophrenia (HR: 1.21) had the next highest probabilities. Risk of admission was highest for > or = 3 outpatient medical visits (HR: 2.61), followed by any inpatient medical/surgical days (HR: 1.79) or outpatient mental health visits (HR: 1.30). Elderly patients with any inpatient mental health days were less likely to be admitted; younger patients with nursing home use, community residential care, and mental health intensive care management were more likely to be admitted. CONCLUSION: Given that mental illness is independently associated with the likelihood of admission, it is critical that providers develop the skills and resources necessary to meet the psychiatric needs of home care recipients.     

Prevalence of human immunodeficiency virus,hepatitis B,and hepatitis C among homeless persons with co-occurring severe mental illness and substance use disorders

This study was undertaken to determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among homeless persons with co-occurring severe mental illness (SMI) and substance use disorders and to determine associated risk factors. As part of a longitudinal study of the effectiveness of integrated treatment for homeless persons with SMI and substance abuse or dependence, serological testing was performed to ascertain the prevalence of HIV, HBV, and HCV. At baseline, 6.2% of participants (11/172) were HIV-positive. Nearly one third of participants (37/114) had evidence of prior exposure to HBV, and 30% (34/114) were antibody positive for HCV. About 44% of participants (50/114) had a reactive test for either HBV or HCV. Having a reactive test was strongly associated with substance use, especially with a history of injection drug use. A significant threat exists to the health and well-being of homeless person with SMI due to high prevalence of blood-borne pathogens. Mental health providers need to play a proactive role in the identification of health-related needs and to assist with access to general health services for persons with SMI.