Disability and service use among homeless people living with psychotic disorders

BACKGROUND: The prevalence of psychosis and needs for care among homeless people were studied in inner Melbourne. METHOD: This was a two-stage nested study within the Australian National Survey of People Living with Psychotic Illness. A screen for psychosis was administered to a representative sample of men and women living in marginal housing in a mental health service catchment area. A selected subsample of 82 screen-positive respondents was interviewed using the Diagnostic Interview for Psychosis (DIP), a semistructured, standardized interview with three modules: (i) demography, functioning and quality of life; (ii) diagnosis; and (iii) service use. RESULTS: An unexpectedly high prevalence of people living with psychotic disorders (estimated lifetime prevalence 42%, 95% CI=37-47%) may reflect a concentration of vulnerable people in the shrinking marginal housing supply in the inner city areas. Disability in everyday, occupational and social functioning is greater for this subgroup than for other people living with psychosis in Australia. Most people were single and unemployed, and many reported social isolation and feeling unsafe. Substance use disorders were common. Most people were using health services, including specialist mental health services, but few were receiving rehabilitation, vocational or housing support. CONCLUSIONS: Despite high levels of contact with a well-organized, sectorized mental health service in an affluent country, this pocket of several hundred people had high levels of persisting disability and needs. The literature and local experience suggest that changing this situation is likely to require co-ordinated policy and practice between the health, welfare and housing sectors.     

Substance use disorders among homeless people in inner Sydney

  Background: The study aimed to assess the prevalence of alcohol and drug use disorders among homeless people in inner Sydney, to compare the Australian findings with the international literature and to examine treatment seeking. Method: Two hundred and ten homeless men and women randomly selected from the dining rooms of inner Sydney refuges were interviewed. DSM-IV diagnoses over the past 12 months were based on the Composite International Diagnostic Interview (CIDI). Results: Half the homeless men and 15% of the women had a diagnosis of alcohol use disorder in the past 12 months. One in five had an opiate use disorder, one in five a cannabis use disorder and one in ten a sedative or stimulant use disorder. Conclusions: Drug use disorders were more prevalent in this Australian sample than in comparable international studies. Accepted: 31 May 2000     

Needs for mental health care and service provision in single homeless people

Background: Specific problems in sampling methodology, case-finding strategies and a standardised needs assessment in mentally ill homeless people have contributed to their being neglected as a mental health care clientele. Method: We assessed a representative sample of homeless people (n=102) in the highly industrialised city of Mannheim (Germany) regarding their prevalence of mental disorders (using the SCID) and their needs for mental health care (using the NCA). Results: We found high prevalences, with 68.6 % of all assessed homeless persons having a current mental disorder. Thus, needs for mental health care were very common, with unmet needs predominating in all problem areas, which was supported by a very weak service utilization. Thus, even in a region with a comprehensive community mental health care network, like the study area, mentally ill homeless people are widely under-provided. Conclusions: Results suggest that the traditional shelter system for homeless people carries most of the mental health care burden for their clientele and must be supported by adequate interventions from community-based mental health care services. A closer connection of both sectors and a better co-ordination of the care offers seems to be a prerequisite for helping to reduce unmet mental health care needs in this specific high-risk group. Accepted: 2 January 2001     

Mental health, alcohol and drug use, and criminal history among homeless adults

As part of a community-based survey of 529 homeless adults, the authors analyzed factors associated with their use of mental health services. Homeless persons who had had a previous psychiatric hospitalization were the least likely to sleep in an emergency shelter, had been homeless nearly twice as long as the rest of the sample, had the worst mental health status, used alcohol and drugs the most, and were the most involved in criminal activities. The majority had not made an outpatient mental health visit in 5 years. It is suggested that diverse systems of care are needed for homeless persons.     

Combat stress, psychosocial adjustment, and service use among homeless Vietnam veterans.

Clinical data were gathered on 627 homeless Vietnam veterans evaluated in a Department of Veterans Affairs clinical program for homeless mentally ill veterans. More than two-fifths (43 percent) of the 627 veterans showed evidence of combat stress that was associated with more severe psychiatric and substance abuse problems, although not with greater social dysfunction. In comparison with Vietnam veterans assessed in a national epidemiological study, homeless veterans were severely socially and vocationally dysfunctional. While homeless mentally ill veterans with combat stress used VA mental health services more frequently than did homeless mentally ill Vietnam veterans with other disorders, many received no mental health services. Combat stress appears to be a significant problem among homeless mentally ill Vietnam veterans.     

Mental health in pediatric settings: distribution of disorders and factors related to service use

OBJECTIVES: To examine child psychiatric disorders in pediatric settings and identify factors associated with parents' use of pediatricians as resources concerning emotional/behavioral issues and use of mental health services. METHOD: The sample consists of 5- to 9-year-olds (mean = 7.17 years, SD = 1.41) from a representative sample (N = 1,060) of pediatric practices. Parent interviews included assessments of psychiatric disorders with the Diagnostic Interview Schedule for Children (DISC-R), parental depression/anxiety, possible child abuse, stress, support, and the use of mental health services. RESULTS: The prevalence of any DISC disorder was 16.8%. Parental depression/anxiety and possible child abuse were associated independently with 2- to 3-times higher rates of disorder. Many parents (55%) who reported any disorder did not report discussing behavioral/emotional concerns with their pediatrician. Factors associated with discussing behavioral/emotional issues were the presence of any disorder and financial stress. Factors related to seeing a mental health professional were discussing behavioral/emotional issues with the pediatrician, single parenthood, and stressful life events. CONCLUSIONS: The prevalence rates of disorders in this setting suggest that pediatricians are well-placed to identify and refer children with psychiatric disorders. However, most parents do not discuss behavioral/emotional issues with their pediatrician. Methods for improving rates of identification and referral (e.g., routine screening) are considered.     

Children in foster care: Mental health, service use and costs

Abstract Objective To assess the prevalence of mental health problems in children in foster care, their families’ use of services and the associated costs. Methods Information on mental health problems, service use and costs was collected, by postal questionnaires and home interviews, on 182 children, their foster carers and teachers from 17 local authorities in Central Scotland. Results Over 90% of the children had previously been abused or neglected and 60 % had evidence of mental health problems including conduct problems, emotional problems, hyperactivity and problems with peer relations. When compared with 251 children from local schools, the children in foster care had significantly higher symptom scores for Reactive Attachment Disorder. Those children with highest scores for mental health problems were attracting a high level of service support from a wide range of agencies, except Child and Adolescent Mental Health Services (CAMHS). Costs were associated with learning disability, mental health problems, and a history of residential care. Conclusions Children in “mainstream” foster care are at greater risk of mental health problems, and are attracting greatest costs, but CAMHS are not successfully targeting these problems. CAMHS may need to develop new models of service delivery.     

Intention to undergo dementia screening in primary care settings among community-dwelling older people

To improve the quality of care for people with dementia, several local governments in Japan have implemented a subsidized system for screening of dementia. This cross-sectional study aimed to identify factors that promote public intention to undergo dementia screening. A postal survey was conducted in a residential area that lies across the two cities which started a subsidized system for dementia screening. Semi-structured questionnaires were distributed to community-dwelling people aged ≥65 years; a total of 2269 persons were included in the analysis. χ² test and multiple logistic regression analysis were used to identify factors associated with the willingness to undergo dementia screening. Among the people with dementia, only 28% had undergone a screening test for dementia. The participants who were certified of public long-term care need tended to undergo dementia screening. Approximately 67% of the participants were willing to undergo a dementia diagnosis test. Younger age, female sex, perceived poor health status, having a primary care physician, and independent daily activity level were associated with a greater willingness to undergo dementia screening using a subsidized system. Our study showed that majority of people with possible dementia do not undergo dementia screening. However, majority of people were willing to use a subsidized system for dementia screening. Further studies are required to support the benefits of a subsidized dementia screening in primary care settings. J Am Geriatr Soc 68:-, 2020.     

Trauma and posttraumatic stress disorder in an urban Xhosa primary care population: prevalence,comorbidity, and service use patterns

Despite increased awareness of the prevalence and morbidity of psychiatric illnesses, relatively few studies have been undertaken in primary care settings in the African context. The authors determined the prevalence of trauma exposure and posttraumatic stress disorder (PTSD) in a South African township primary health care clinic and assessed associated demographic factors, comorbidity, service use, service satisfaction, and quality of life. Subjects were directly interviewed using translated, standardized instruments to assess variables described. Retrospective chart analysis assessed clinician case identification and psychotropic drug-prescribing habits. Of the 201 participants, 94% reported exposure to traumatic events (mean, 3.8). Trauma was associated with single status (p =.01), and PTSD was associated with poverty and single status (p =.04). Both sexes were equally likely to develop PTSD. PTSD (current; 19.9%), depression (37%), and somatization disorder (18.4%) were the most common diagnoses. Comorbidity with PTSD was high and included depression (75%, p <.01), somatization (35%, p <.01), and panic disorder (25%, p <.01). Levels of functional impairment were higher for subjects with PTSD, depression, and somatization than for those without (p <.05). PTSD comorbid with depression compounded impairment (p =.04). Levels of trauma, PTSD, and depression did not increase service use or dissatisfaction with services. Clinicians did not identify trauma (0%) or psychopathology (0%), and psychotropic medication was prescribed for only 1% of participants. In this population, trauma and PTSD were highly prevalent and associated with significant unidentified morbidity and comorbidity. Patients remain untreated for years in the current system of primary care consultations.     

The prevalence of psychiatric disorders and use of care by homeless people in Paris

Background: Homelessness is a growing problem in the cities of the western world, and homeless people have a plethora of mental health and social difficulties. These are, nevertheless, difficult to evaluate epidemiologically. Method: In this paper we present a population survey using the Composite International Diagnostic Interview (CIDI) conducted in the city of Paris in winter 1996 on a representative sample of 838 homeless people. Night shelters as well as food kitchens were randomly sampled, and the mean response rate was around 65%. Results: The sample was relatively young and predominantly male (85%). Forty percent were born outside France, 96% had worked at some time, and one-third reported no resources at all. The lifetime prevalence of psychiatric disorders was 57.9%, while the 1-year prevalence was 29.1%. For definite psychotic disorders, prevalence was 16% (lifetime) and 6% (1-year). Generally, this Parisian homeless population had some access to care: in the preceding 6 months 57.7% of them had been medically attended and 14.2% of these had been hospitalised. The survey was cross-sectional, and did not evaluate regular access to care or the quality of care. Conclusions: The implications for health and social systems are discussed in the light of comparisons with European and North American data. Accepted: 25 June 1999     

Social support and service use among homeless persons with serious mental illness.

It has been widely hypothesized that persons with greater social support use fewer health care services, although previous studies have shown variable results. This study examines the relationship between levels of social support and formal service use among clients entering 18 community treatment programs for homeless persons with serious mental illness as part of the ACCESS demonstration project of the U.S. Center for Mental Health Services. Baseline and follow-up data on 1,828 clients entering the ACCESS program were used to evaluate the relationship between individual client socio-demographic and clinical characteristics, seven measures of social support, and levels of formal service use in this population. Three measures of social support were positively related to the use of outpatient medical services and one each to the use of substance abuse services and the total days of service use. Six out of seven measures of social support were positively related to the receipt of multiple services. It appears that social support is most strongly associated with improved access to an array of different services--a very important need among this population.     

Mental health needs, service use and costs among Somali refugees in the UK

OBJECTIVE: To assess the mental health needs and service use of Somali refugees living in London. METHOD: Subjects (n = 143) were sampled from conventional and non-conventional sites. Needs and service use were measured using the Camberwell Assessment of Need and the Client Service Receipt Inventory, respectively. Comparisons between sites were made and cost predictors identified. RESULTS: Basic needs occurred frequently but were often not fully addressed. The mean number of needs was around four out of a possible 22. The most used services were GPs, other clinicians and refugee services. Higher non-inpatient costs were associated with length of stay in the UK and lower costs with being at risk of suicide and having panic disorder or agoraphobia. CONCLUSION: Somali refugees living in London have a relatively high level of need but a low level of service use. Refugee characteristics could only account for a limited amount of cost variation.     

Outcomes and service use among homeless persons with serious mental illness and substance abuse

OBJECTIVE: This study compared baseline characteristics and clinical improvement after 12 months among homeless persons with a diagnosis of serious mental illness with and without a comorbid substance use disorder. METHODS: The study subjects were 5,432 homeless persons with mental illness who were participating in the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program. Analysis of covariance was used to compare clients who had dual diagnoses and those who did not and to identify any association between service use and clinical improvement. RESULTS: Follow-up data were available for 4,415 clients (81 percent). At baseline, clients with dual diagnoses were worse off than those without dual diagnoses on most clinical and social adjustment measures. Clients with dual diagnoses also had poorer outcomes at follow-up on 15 (62 percent) of 24 outcome measures. However, among clients with dual diagnoses, those who reported extensive participation in substance abuse treatment showed clinical improvement comparable to or better than that of clients without dual diagnoses. On measures of alcohol problems, clients with dual diagnoses who had a high rate of participation in self-help groups had outcomes superior to those of other clients with dual diagnoses. Clients with dual diagnoses who received high levels of professional services also had superior outcomes in terms of social support and involvement in the criminal justice system. CONCLUSIONS: Homeless persons with dual diagnoses had poorer adjustment on most baseline measures and experienced significantly less clinical improvement than those without dual diagnoses. However, those with dual diagnoses who received extensive substance abuse treatment showed improvement similar to those without at 12 months.     

Mental health services for American Indians and Alaska Natives: need, use, and barriers to effective care.

This special review summarizes and illustrates the state of our knowledge regarding the mental health needs of American Indians and Alaska Natives. These needs are considerable and pervasive. The discussion begins by reflecting on the limits of psychiatric nomenclature and conceptual frameworks for revealing Native constructions of mental health and mental illness. The experience and manifestation of psychopathology can be both different and the same across cultures, hinging upon the extent to which such basic assumptions as the relationship of mind to body--and spirit in the case of Native people--or the primacy of the individual or social collective are shared. Having set the stage, this paper moves to recent empirical evidence regarding the mental health needs of American Indians and Alaska Natives: we review that evidence and consider it within the broader context of available services. The report closes with a brief overview of the most pressing issues and forces for change afoot in Indian country in the US. Most have to do with the structure and financing of care as tribes and other Native community-based organizations seek to balance self-determination and resource management to arrive at effective, fiscally responsible, culturally informed prevention, treatment, and aftercare options for their members. These changes may herald similar trends among First Nations people to the immediate north.     

Mental disorder among homeless persons in the United States: An overview of recent empirical literature

Reviewed literature on the homeless reports higher rates of psychiatric disorder, psychological distress, and previous psychiatric hospitalization compared to the general population. However, understandardized methodology and lack of consistent findings across studies prohibit reliable prevalence estimates of mental disorder among the homeless.Dr. Robertson is with the Center for Research of Women of Wellesley College, Wellesley, Massachusetts 02181.     

Health status,service use,and costs among veterans receiving outreach services in jail or community settings

OBJECTIVE: This study compared client characteristics, service use, and health care costs of two groups of veterans who were contacted by outreach workers: a group of veterans who were contacted while incarcerated at the Los Angeles jail and a group of homeless veterans who were contacted in community settings. METHODS: Between May 1, 1997, and October 1, 1999, a total of 1,676 veterans who were in jail and 6,560 community homeless veterans were assessed through a structured intake procedure that documented their demographic, clinical, and social adjustment characteristics. Data on the use and costs of health services during the year after outreach contact were obtained from national databases of the Department of Veterans Affairs (VA). Chi square and t tests were used for statistical comparisons. RESULTS: The veterans who were contacted in jail obtained higher scores on several measures of social stability (marital status and homelessness status) but had higher rates of unemployment. They had fewer medical problems but higher levels of psychiatric and substance use problems, although the rate of current substance use was lower among these veterans than among the community homeless veterans. One-year service access for the jailed veterans was half that of the community homeless veterans. No differences were observed in the intensity of use of mental health services among those who used services, but the jailed outreach clients used fewer residential, medical, and surgical services. Total health care expenditures for the veterans who received outreach contact in jail were $2,318 less, or 30 percent less, than for those who were contacted through community outreach. CONCLUSIONS: Specialized outreach services appear to be modestly effective in linking veterans who become incarcerated with VA health care services. Although it is clinically challenging to link this group with services, the fact that the rate of current substance use is lower during incarceration may provide a window of opportunity for developing linkages between inmates and community rehabilitative services.     

Age differences in posttraumatic stress disorder, psychiatric disorders, and healthcare service use among veterans in Veterans Affairs primary care clinics.

OBJECTIVE: To expand our understanding of posttraumatic stress disorder (PTSD) prevalence, its psychiatric characteristics, and service use among elderly veterans in Veterans Affairs (VA) primary care clinics. METHODS: A cross-sectional, epidemiological design (N = 745) incorporating self-report measures, structured interviews, and chart reviews was used to obtain relevant information for analyses. RESULTS: The oldest group of veterans (>or=65 years; N = 318) had lower prevalence of most psychiatric diagnoses than the youngest (18-44 years; N = 69) and middle-aged (45-64 years; N = 358) groups. Despite having higher rates of combat exposure, veterans in the oldest group (6.3%) had one-third the prevalence of PTSD than those in the middle-aged group (18.6%). A similar pattern was found across other psychiatric diagnoses. For example, those in the oldest group (7.5%) had one-third the prevalence of major depression as those in the two younger groups (21.7% and 22.9%). These differences were maintained after controlling for relevant demographic covariates (race, sex). Results from examination of VA health care service use across the three groups were consistent with the findings that the oldest veteran group is functioning significantly better across mental health domains. CONCLUSION: Elderly veterans who use VA primary care services evidence lower rates of PTSD and other psychiatric disorders, and they use significantly less VA mental health services. They also do not appear to show evidence of worse physical health functioning or use VA health care services or disability benefits at a meaningfully higher rate than their younger counterparts.     

Perceived unmet need for mental health treatment and barriers to care among patients with panic disorder

OBJECTIVE: This study estimated the extent of perceived unmet need for mental health treatment among individuals with panic disorder in primary care settings, investigated the determinants of unmet need, and assessed barriers to care. METHODS: Data were from baseline interviews in a clinical trial that investigated primary care treatment of panic disorder. Participants were asked whether there was any time in the past three months when they did not get as much care for emotional or personal problems as they needed or whether they had delays in getting care. Patients who endorsed unmet need were asked about specific perceived barriers. Logistic regression was used to investigate the determinants of unmet need. RESULTS: Of the 231 patients eligible for the study, 88 (38 percent) endorsed unmet need for emotional or mental health problems. Individuals with worse mental health, those who were more worried about panic, and those without sick pay were significantly more likely to report unmet need. Commonly reported barriers included being unable to find out where to go for help (43 percent), worry about cost (40 percent), lack of coverage by health plan (35 percent), and being unable to get an appointment soon enough (35 percent). CONCLUSIONS: The relatively low level of patient-reported unmet need for mental health treatment among primary care patients with panic disorder suggests that efforts to improve treatment of panic disorder should include patient education about mental illness and the effective treatments available. Although discussion of barriers to care has traditionally centered on stigma and economic factors, the results of this study suggest that simple logistic factors, such as not knowing whom to call for help, are also important barriers.