Use of Mental Health Services by Youths in Public Sectors of Care

The present paper examined the lifetime rates of mental health service use in a representative sample of youths identified as receiving services in at least one sector of care in a publicly funded service system of a large, metropolitan area. Service use was examined in relation to age, gender, mental health diagnostic status, and service sector involvement. Participants were 1706 youths ages 6-17 years who were active in at least one of the following service sectors: alcohol and drug services, child welfare, juvenile justice, mental health, and special education services for serious emotional disturbance. Structured service use and diagnostic interviews were administered to youths and their caregivers. High lifetime rates of mental health service use were found. Eighty-seven percent of the sample used at least one outpatient service, 45% used at least one inpatient service, and 71% reported use of a school-based service. Youths involved with the mental health and special education sectors had the highest rates of service use. In contrast, youths enumerated from the juvenile justice system tended to have the lowest rates of use. Additional research is needed to refine our understanding of the factors associated with the observed patterns of service use.     

Experiences of and attitudes toward mental health services among older youths in foster care

OBJECTIVES: This study explored the experiences of youths in the Missouri foster care system who were receiving mental health services in order to identify characteristics that they valued in relationships with mental health professionals and in the services they received and to examine whether their attitudes toward services were associated with their experiences with services. METHODS: As part of a larger study, 389 youths aged 17 years were asked open-ended questions about their experiences with mental health providers. The qualitative responses were classified through thematic analysis, and the frequencies of themes were assessed. Service use was measured, and the confidence subscale of the Attitude Toward Seeking Professional Psychological Help scale was used to measure attitudes. RESULTS: Youths' comments generally centered on three aspects of their mental health care: their relationship with their mental health provider, the level of professionalism of their provider, and the effects of the treatment, including medication management. Youths who reported only negative experiences had less positive attitudes toward services than other youths, but they were not any more likely to have experienced changes in service use or medication six months later. CONCLUSIONS: Soliciting feedback from youths about mental health services is important to the provision of high-quality care. In addition to themes identified in similar studies, this study suggests that medication management plays an important role in the acceptability of the treatment that youths receive.     

Multimodal treatment for ADHD among youths in three Medicaid subgroups: disabled, foster care, and low income

OBJECTIVE: This study compared the use of treatments for attention-deficit hyperactivity disorder (ADHD) among three distinct subpopulations of Medicaid-insured youths who have very different mental health needs and patterns of service use: those with federally documented disability, those in foster care, and those in families with low income. METHODS: This one-year, cross-sectional study of community mental health services used administrative data. Individuals who were younger than 20 years, who were continuously enrolled in one Mid-Atlantic state Medicaid program, and who had two or more medical encounters associated with an ADHD diagnosis in 1998 were identified (N=1,296). Measures of the use of mental health services were the number of different classes of psychopharmacologic medications, the psychopharmacologic regimen, and the combined use of pharmacotherapy and psychotherapy treatments (multimodal treatment). RESULTS: Use of multiple psychopharmacologic agents was greater in the disabled and foster care groups compared with the low-income group. Significantly fewer mental health provider visits, but greater use of stimulant treatment only, were observed in the low-income group compared with the other groups. Youths in the disabled group were significantly more likely than youths in the low-income group, but not more likely than youths in the foster care group, to receive multimodal treatments. Children in foster care were significantly more likely than those in the other groups to use a substance abuse service. CONCLUSIONS: Among a cohort of Medicaid-enrolled youths with ADHD, co-existing psychiatric disorders and complex psychopharmacologic treatments were more common in the disabled and foster care groups than in the low-income group. Youths with disabilities were significantly more likely than youths in the low-income group to receive multimodal treatment.     

Pathways into and through mental health services for children and adolescents

OBJECTIVE: This study examined points of entry into the mental health service system for children and adolescents as well as patterns of movement through five service sectors: specialty mental health services, education, general medicine, juvenile justice, and child welfare. METHODS: The data were from the Great Smoky Mountains Study, a longitudinal epidemiologic study of mental health problems and service use among youths. The sample consisted of 1,420 youths who were nine, 11, or 13 years old at study entry. Each youth and a parent were interviewed at baseline and every year thereafter about the use of services for mental health problems over the three-year study period. RESULTS: Population estimates indicated that 54 percent of youths have used mental health services at some time during their lives. The education sector was the most common point of entry and provider of services across all age groups. The specialty mental health sector was the second most common point of entry for youths up to age 13 years, and juvenile justice was the second most common point of entry for youths between the ages of 14 and 16. Youths who entered the mental health system through the specialty mental health sector were the most likely to subsequently receive services from other sectors, and those who entered through the education sector were the least likely to do so. CONCLUSIONS: The education sector plays a central role as a point of entry into the mental health system. Interagency collaboration among three primary sectors-education, specialty mental health services, and general medicine-is critical to ensuring that youths who are in need of mental health care receive appropriate services.     

Mental health and medical problems and service use among adolescent substance users

OBJECTIVE: Adolescents entering the substance abuse treatment system frequently exhibit mental health and medical problems. Because little is known about whether these youths receive services to address these problems, this study examined the services received by youths admitted to substance abuse treatment. METHOD: Admission and 3-month follow-up reports of mental health, medical problems, and service use were examined within a large cohort (N = 1,088) of 12-19-year-olds admitted to seven inpatient and outpatient substance abuse treatment programs across the United States between 1998 and 2001. RESULTS: High levels of mental health problems were found at both time points, but few received mental health treatment. In contrast, there were lower rates of medical problems, and more than half received services. Logistic regression predicting mental health treatment receipt found females in residential settings with more current and baseline distress to be more likely to receive services. Ethnicity, baseline behavioral problems, and whether or not currently in substance abuse treatment did not predict service use. A logistic regression predicting medical services showed that females in residential treatment were also more likely to receive medical treatment. CONCLUSION: Although these results require replication and validation, they suggest that more could be done to take advantage of the opportunity to link youths entering substance use treatment with mental health services.     

Prevalence of psychiatric disorders among older youths in the foster care system

OBJECTIVE: To estimate the lifetime and past year prevalence rates of major psychiatric disorders in a sample of older youths in the foster care system, to examine the timing of disorder onset and system entry, and to explore variations in past year prevalence rates. METHOD: Using the Diagnostic Interview Schedule for DSM-IV, interviews were conducted with 373 17-year-old youths (90% of those eligible) in one state's foster care system between December 2001 and June 2003. RESULTS:: Sixty-one percent of the youths qualified as having at least one psychiatric disorder during their lifetime; of these youths, 62% reported onset of their earliest disorder before entering the foster care system. In addition, 37% of youths met criteria for a psychiatric disorder in the past year. The number of types of maltreatment experienced was the most robust predictor of psychiatric disorder among several maltreatment variables. There were no differences in prevalence rates for youths in kinship care and those in nonkin foster families. CONCLUSIONS: Older youths in the foster care system have disproportionately high rates of lifetime and past year psychiatric disorders. Results support recommendations for initial and periodic mental health assessments for these youths and mechanisms to continue mental health services for young adults transitioning out of the foster care system.     

Mental health need and access to mental health services by youths involved with child welfare: a national survey

OBJECTIVE:This study assessed the relationship between the need for and use of mental health services among a nationally representative sample of children who were investigated by child welfare agencies after reported maltreatment. METHOD: Data were collected at study entry into the National Survey of Child and Adolescent Well-Being and were weighted to provide population estimates. RESULTS: Nearly half (47.9%) of the youths aged 2 to 14 years (N = 3,803) with completed child welfare investigations had clinically significant emotional or behavioral problems. Youths with mental health need (defined by a clinical range score on the Child Behavior Checklist) were much more likely to receive mental health services than lower scoring youth; still, only one fourth of such youths received any specialty mental health care during the previous 12 months. Clinical need was related to receipt of mental health care across all age groups (odds ratio = 2.7-3.5). In addition, for young children (2-5 years), sexual abuse (versus neglect) increased access to mental health services. For latency-age youths, African-American race and living at home significantly reduced the likelihood of care. Adolescents living at home were also less likely to receive services, whereas having a parent with severe mental illness increased (odds ratio = 2.4) the likelihood of service use. CONCLUSIONS: Routine screening for mental health need and increasing access to mental health professionals for further evaluation and treatment should be a priority for children early in their contact with the child welfare system.     

Mental health services for Latino adolescents with psychiatric disorders

OBJECTIVES: The major objectives of this study were to examine the prevalence of mental disorders and the use of mental health services among Latino adolescents who were receiving services in at least one of five public sectors of care in San Diego County. METHODS: Survey data were gathered for a random sample of adolescents aged 12 to 18 years (N=1,164) who were receiving public-sector care. Mental disorders were assessed with the Diagnostic Interview Schedule for Children, and use of mental health services was assessed with the Service Assessment for Children and Adolescents. RESULTS: Rates of disruptive disorders were significantly lower among Latino adolescents than among white adolescents. Although more than half of the Latino sample received specialty mental health services, those with psychiatric disorders were significantly underserved compared with their white counterparts. Latino adolescents with psychiatric disorders entered specialty mental health services at a later age and had made significantly fewer specialty mental health service visits in the previous year. In multivariate analyses, Latino youths were significantly less likely than white youths to use specialty mental health services independent of diagnosis, gender, age, and the service sector from which they were selected. CONCLUSIONS: Public service systems need to ensure that Latino youths are appropriately assessed for disruptive disorders and that they are provided with appropriate specialty mental health care.     

Exploring the Relationship Between Race/Ethnicity,Age of First School-Based Services Utilization,and Age of First Specialty Mental Health Care for At-Risk Youth

This study investigated race/ethnic variations in age of entry into school-based services and specialty mental health outpatient services among 1552 high-risk youths served in a publicly funded system of care. Non-Hispanic White youths were more likely to receive school-based services as compared to ethnic minority groups, and to begin use at an earlier age. In addition, the earlier a child was identified for school-based services, the earlier the child first utilized specialty outpatient mental health services. Multiple regression models showed that inclusion of race/ethnicity as a predictor significantly increased the overall variance explained in the model predicting age of first school-based services, and both race/ethnicity and first use of school-based services increased the overall variance explained in the model predicting age of first specialty mental health outpatient service use. The results suggest that involvement in school-based services may play an important role in facilitating specialty outpatient mental health service use for youths.     

Utilization of alcohol, drug, and mental health treatment services among American Indian adolescent detainees.

OBJECTIVE: To describe the relationship between psychiatric status and the use of alcohol, drug, and mental health (ADM) services among a sample of American Indian (AI) juvenile detainees. METHOD: A structured diagnostic and service use interview was administered to 150 AI youths detained in a juvenile detention center located on a Northern Plains reservation. RESULTS: Forty percent of AI youths with a diagnosed substance use disorder and 34.1% with a diagnosed anxiety, mood, or disruptive behavior disorder reported lifetime use of services for substance use and emotional problems, respectively. While services for substance use problems were most commonly provided in residential settings, services for emotional problems were most commonly provided in outpatient settings. Traditional healers and pastoral counselors provided services to 23.7% and 29.6% of youths who received services for substance use and emotional problems, respectively. Detained youths were more likely to receive ADM services than AI adolescents living at--large in another, comparable Northern Plains reservation community. Still, the vast majority of youths in detention who suffered from psychiatric disorders did not report use of ADM services. CONCLUSIONS: Detention facilities serving AI adolescents need to screen carefully for the presence of psychiatric disorders and facilitate the use of ADM services.     

Unmet needs for substance abuse and mental health services among Northern Plains American Indian adolescents

Use of mental health and substance abuse services was examined among 109 American Indian adolescents in a Northern Plains reservation community. Each was interviewed to assess psychiatric diagnosis and service use and to determine whether an adult had recognized a problem in the adolescent-a critical determinant of receipt of services. Of the 23 youths who had a disorder, nine (39 percent) reported lifetime service use. Of the 25 who received services, 17 were treated by a school counselor; only one received services from a mental health specialist. Eight of the 25 youths with a psychiatric or substance use diagnosis who did not receive services reported that an adult had recognized a problem.     

Access to and patterns of use of behavioral health services among children and adolescents in TennCare

OBJECTIVE: This study assessed trends in access to and use of behavioral health services for school-aged children in TennCare, Tennessee's Medicaid managed care program, between state fiscal years 1995 and 2000. METHODS: Claims, encounter, and enrollment data from the Bureau of TennCare were used. The data analyzed were restricted to services and enrollment periods for children and adolescents between the ages of four and 17 years at the time of service or enrollment. Measures were calculated in four areas: overall access to behavioral health services, use of inpatient services, use of outpatient specialty treatment services, and use of supportive services like case management and medication management. RESULTS: The number of youths who received a behavioral service increased by nearly 50 percent between state fiscal years 1995 and 2000. At the same time, the number of youths enrolled in TennCare increased by 19 percent. The annual access rate increased from 72.7 youths per 1000 enrollees to 91.7. However, the volume of services for children fell. Access rates were low relative to estimates of need in this population. The system made less use of inpatient services and relied more on outpatient services, particularly case management and medication management services. CONCLUSIONS: Children's access rates for behavioral health services improved even as the TennCare program expanded to cover more children. The system served more youths in part by reducing the volume of services for children receiving treatment and substituting more supportive services. Ongoing performance monitoring for policy making will require enhancements of data monitoring activities by the state.     

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.     

Use and costs of public-sector behavioral health services for african-american and white women

OBJECTIVE: The purpose of this study was to identify differences between African-American and white women in the use of behavioral health services and factors associated with these differences. METHODS: In one large public behavioral health system, data on demographic characteristics, financial resources, clinical disorders, service use patterns, and costs of care were analyzed for 10,905 African-American and 19,069 white women between the ages of 18 and 59 years who received behavioral health services in 1997. RESULTS: The African-American women were more likely to be older, never married, unemployed, and eligible for Medicaid and to have a diagnosis of a psychotic disorder or a substance use disorder. African-American women were more likely than white women to receive inpatient substance abuse services and to receive more community-based day treatment services, medication services, and case management services. However, the costs of that care differed by only 2 to 4 percent from those for white women. Presence of a psychotic disorder and co-occurring substance use-need-related factors-were significant predictors of higher inpatient care costs for all the women in the sample. Presence of a psychotic or major affective disorder and eligibility for Medicaid-an enabling factor-were the most significant predictors of higher outpatient costs for the sample. Receipt of more community-based services was significantly and inversely related to inpatient care costs, regardless of race. CONCLUSIONS: In this sample of African-American and white women, consumers' needs were a significant predictor of service use. Patterns of care that were tailored to consumers' needs were not significantly more costly overall.     

Arrest rates among young adult psychiatric patients treated in inpatient and outpatient settings

Within a statewide random sample of 611 young adult patients who received public inpatient, outpatient, and community residential care, 38 percent were found to have been arrested at least once in their adult lifetimes. Thirty-five percent had been arrested for felonies and 18.9 percent for violent crimes. Analyses by five major diagnostic groups showed that patients with a primary diagnosis of drug or alcohol abuse had the greatest overall frequency of arrests and also the greatest frequency of arrests for burglary, offenses against public order such as peace disturbance or loitering, and probation and parole violations. No significant differences between diagnostic groups were found for arrests for violent crimes. Characteristics that predicted which patients would be arrested in the year after receiving mental health services were a greater number of lifetime felony arrests, younger age, being black or a member of another minority group, and more years since first receiving public mental health care.     

Racial and ethnic differences in utilization of mental health services among high-risk youths

OBJECTIVE: Racial and ethnic disparities in mental health service use have been identified as a major public health problem. However, the extent to which these disparities may be accounted for by other confounding sociodemographic or clinical predictors of service use (e.g., family income, functional impairment, caregiver strain) is relatively unexplored, especially for youth services. The goal of this study was to test for racial/ethnic disparities in use of a variety of outpatient, inpatient, and informal mental health services among high-risk youths, with the effects of other predictive factors controlled. METHOD: Participants were 1,256 youths ages 6-18 years who received services in a large, publicly funded system of care (including the child welfare, juvenile justice, special education, alcohol and drug abuse, and mental health service sectors). Youths and caregivers were interviewed with established measures of mental health service use, psychiatric diagnoses, functional impairment, caregiver strain, and parental depression. RESULTS: Significant racial/ethnic group differences in likelihood of receiving any mental health service and, specifically, formal outpatient services were found after the effects of potentially confounding variables were controlled. Race/ethnicity did not exert a significant effect on the use of informal or 24-hour-care services. CONCLUSIONS: Racial/ethnic disparities in service use remain a public health problem.     

Mental health service use by adolescents in the 1970s and 1980s

Shifts in the use of mental health services by adolescents between 1975 and 1986 are examined by levels of care--outpatient, partial hospitalization, residential treatment center, and inpatient. Data from National Institute of Mental Health surveys of U.S. facilities include client characteristics (age, sex, race, diagnosis, clinical history) and treatment characteristics (referral source, type of intervention, length of stay). Major increases in mental health service use were observed for all levels of care during this period. Nonetheless, a relatively small percent (less than 2%) of adolescents in the U.S. received any type of mental health service in 1986. The clinical and treatment variables available were only moderately helpful in differentiating levels of care.     

Perceived barriers to mental health services among youths in detention

OBJECTIVE: To examine perceived barriers to mental health service use among male and female juvenile detainees. METHOD: The sample included 1,829 juveniles newly detained in Chicago. The Diagnostic Interview Schedule for Children and Children's Global Assessment Scale were used to determine the need for services. Service use and barriers to services were assessed with the Service Utilization and Risk Factors interview. RESULTS: Approximately 85% of youths with psychiatric disorders reported at least one perceived barrier to services. Most common was the belief that problems would go away without help. Generally, attitudes toward services were remarkably similar across sex and race. Among females, significantly more youths with past service use or referral to services reported this barrier than did youths who had never received or been referred to services. Among males, significantly more youths who had been referred, but never received, services were unsure about where to go for help than youths with past service use. Significantly more youths with no past service use or referrals were concerned about the cost of services than youths with past service use. CONCLUSIONS: Despite the pervasive need for mental health services, the findings of this study suggest that detained youths do not perceive the mental health system as an important or accessible resource. Youths who believe their problems can be solved without assistance are unlikely to cooperate with referrals or to independently seek mental health services. Service providers must be sensitive to clients' perceived barriers to mental health services and work to reduce negative perceptions of services.     

Patterns of utilization of outpatient mental health services by children and adolescents.

Although as many as one-fifth of children and adolescents may meet DSM-III criteria for at least one psychiatric diagnosis, data from the Minnesota Department of Human Services for 1988 show that only 20 to 38 percent of children and adolescents in the state who are eligible for medical assistance and who are potentially in need of psychiatric care are referred for or seek treatment. A study of publicly funded mental health care for youths under 18 found that in 1988 the average cost for state-supported psychiatric services per outpatient case was $520, compared with $8,556 per inpatient case. However, overall cost of state-supported mental health services for youths under 18 increased by 28 percent between 1987 and 1988, primarily due to increases in payments for inpatient care of patients with dual diagnoses of mental illness and chemical dependency.     

Public costs of better mental health services for children and adolescents

OBJECTIVE: This study evaluated how improved community mental health services for youths affect public expenditures in other sectors, including inpatient hospitalization, the juvenile justice system, the child welfare system, and the special education system. METHODS: Participants were youths aged six to 17 years who received services through a mental health agency in one of a matched pair of communities. One community delivered mental health services according to the principles of systems of care (N=220). The comparison community delivered mental health services but did not provide for the interagency integration of services (N=211). The analyses are based on administrative and interview data. RESULTS: Preliminary analyses revealed that mental health services delivered as part of a system-of-care approach are more expensive. However, incorporating expenditures in other sectors reduced the between-site gap in expenditures from 81 to 18 percent. This estimate is robust to changes in analytical methods as well as adjustments for differences between the two sites in the baseline characteristics of participants. CONCLUSIONS: These findings suggest that reduced expenditures in other sectors that serve youths substantially, but only partially, offset the costs of improved mental health services. The full fiscal impact of improved mental health services can be assessed only in the context of their impact on other sectors.