Service costs of caring for adolescents with mental illness in a rural community, 1993-2000

OBJECTIVE: Costs of treating child psychiatric disorders fall on educational, primary care, juvenile justice, and social service agencies as well as on psychiatric services. The authors estimated multiagency mental health costs by integrating service unit costs with utilization rates in an 11-county area. Using psychiatric diagnoses made independently of service use records, the authors calculated costs across agencies as well as the extent of unmet need for psychiatric care. METHOD: Annual parent and child reports were used to measure mental health care needs and units of service across 21 types of settings for the population-based Great Smoky Mountain Study sample of 1,420 adolescents from ages 13 to 16. Unit costs for services were generated from information from service providers and records. The authors calculated costs overall, costs by type of service, and costs by diagnosis. RESULTS: Average annual costs per adolescent treated were $3,146. Juvenile justice and inpatient/residential facilities accounted for well over half of the total costs. Costs for youths with two or more diagnoses were twice as much as costs of those with a single disorder. Among adolescents with service needs, 66.9% received no services. Public health insurance was associated with higher rates of specialty mental health care than either private insurance or no insurance. CONCLUSIONS: Annual costs across all services were three to four times greater than recent health insurance estimates alone. Many costs for adolescents with mental health problems were borne by agencies not designed primarily to provide psychiatric or psychological services. Only one in three adolescents needing psychiatric care received any mental health services.     

Caring for mental illness in the United States: a focus on older adults.

OBJECTIVE: The authors compared rates of common mental disorders and the use of primary care and specialty mental health services among younger and older adults. METHODS: They used data from 9,585 respondents to the HealthCare for Communities (HCC) Household Telephone Survey. Mental disorders during the past year, including depression, dysthymia, and generalized anxiety disorder, were identified with a short questionnaire. The survey also collected information about sociodemographic and insurance status, perceived need for mental health care, and use of health services. RESULTS: Older adults (age 65 and older) were significantly less likely than younger adults (18-29) or middle-aged adults (30-64) to meet diagnostic criteria for a mental disorder (8% versus 15% in each of the younger age-groups). Older adults who met diagnostic criteria for mental disorders were less likely to perceive a need for mental health care, to receive specialty mental health care or counseling, or to receive referrals from primary care to mental health specialty care than young or middle-aged adults. CONCLUSION: Few older adults with mental disorders use mental health services, particularly specialty mental health services. The lack of perceived need for mental health care may contribute to low rates of mental health service use among older adults.     

Inequalities in use of specialty mental health services among Latinos,African Americans,and non-Latino whites

OBJECTIVE: The authors investigated whether there are disparities in the rates of specialty mental health care for Latinos and African Americans compared with non-Latino whites in the United States. METHODS: Data were analyzed from the 1990-1992 National Comorbidity Survey, which surveyed a probability sample of 8,098 English-speaking respondents aged 15 to 54 years. Respondents self-identified their race or ethnicity, yielding a sample of 695 Latinos, 987 African Americans, and 6,026 non-Latino whites. Data on demographic characteristics, insurance status, psychiatric morbidity, whether the respondent lived in an urban or a rural area, geographic location, income, and use of mental health services were determined for each ethnic or racial group. Logistic regression analyses were used to examine the associations between ethnic or racial group and use of specialty services, with relevant covariates adjusted for. RESULTS: Significant differences between ethnic groups were found in demographic characteristics, geographic location, zone of residence, insurance status, income, wealth, and use of mental health services. The results indicated that poor Latinos (family income of less than $15,000) have lower access to specialty care than poor non-Latino whites. African Americans who were not classified as poor were less likely to receive specialty care than their white counterparts, even after adjustment for demographic characteristics, insurance status, and psychiatric morbidity. CONCLUSIONS: To understand ethnic or racial disparities in specialty care, the effects of ethnicity or race should be analyzed in combination with variables related to poverty status and environmental context. Further research needs to address the complex construct of social position in order to bridge the gap in unmet need in specialty care.     

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.     

Access to Mental Health Services: Are Uninsured Children Falling Behind?

Previous research has established that insurance status is not a significant determinant of children's use of mental health services (S. Glied, C. W. Hoven, R. E. Moore, A. B. Garrett, & D. A. Regier, 1997; B. J. Burns et al., 1995; P. J. Cunningham & M. P. Freiman, 1996), with uninsured children using no fewer services than privately insured children. However, the introduction of SCHIP, increases in managed care, and mental health parity legislation have all occurred since the last relevant data was collected. Using recent data from the National Survey of America's Families, we find that in 1999, compared with insured children, uninsured children had dramatically reduced access to mental health services. No differences were found in data collected in 1997. This suggests that recent legislative and market changes may have caused children who remain uninsured to be at a significant disadvantage.     

Factors associated with use of mental health services for depression by children and adolescents

OBJECTIVE: This study examined patterns of mental health service use among depressed children and adolescents and factors associated with help seeking and treatment modalities. METHODS: The sample consisted of 206 children and adolescents aged 9 to 17 years who were assessed as part of a larger survey of mental health service use in five service systems and in the community and who met DSM-III-R criteria for depressive disorders (major depression or dysthymia). RESULTS: Among the 206 children, 75 (36 percent) never received professional help for depressive symptoms. Among the 131 children who received professional help for depression, antidepressants were prescribed for 40 (31 percent) in the year before the interview. The findings indicate possible undertreatment of depression among children and adolescents, especially among African Americans. Socioeconomic factors, such as the mother's education and the child's health insurance, were not associated with receiving professional help for depressive symptoms but were associated with receiving antidepressants. Parental perception of a child's mental health service need was associated with receiving professional help but not with receiving antidepressants. Also, depressed children were more likely to receive antidepressants when they had life-threatening or severe symptoms, such as a suicide attempt or drug abuse. CONCLUSIONS: Whether a depressed child receives mental health services and the types of treatment received are influenced by different individual and family factors and by the type of symptoms exhibited. Better understanding of these factors will help in meeting the service needs of depressed children and adolescents.     

Treatment retention among children entering a new episode of mental health care

OBJECTIVE: This study examined use of mental health services among children and adolescents with private insurance who were entering treatment. Variations in service use were examined by age, gender, diagnosis, recent psychiatric hospitalization, and type of insurance. Differences between children who received treatment from mental health professionals and those who were treated by primary care physicians were also examined. METHODS: Drawn from a large database, the sample comprised 11,659 new users of mental health services. Service use was defined as the total number of days children were retained in treatment and the total number of mental health contacts recorded. RESULTS: The overall mean number of visits within a six-month period was 3.9. The average duration of treatment was 75.36 days. Children who were treated by a mental health specialist were less likely to drop out of treatment and had a larger number of visits. Severity of illness, psychiatric hospitalization, and managed care insurance coverage were also associated with lower risk of dropout and greater intensity of care. CONCLUSIONS: Children's access to services does not guarantee sustained involvement in treatment. To more fully address the nature of service use among children, a closer look at specific barriers to continued involvement in services is needed.     

Do Canada and the United States differ in prevalence of depression and utilization of services?

OBJECTIVE: This study compared the prevalence of depression and the determinants of mental health service use in Canada and the United States. METHODS: The study used data from preliminary analyses of the 2003 Joint Canada/United States Survey of Health, which measured Canadian (N=3,505) and United States (N=5,183) resident ratings of health and health care services. Cross-national comparisons were made for the 12-month prevalence of DSM-IV major depression, 12-month service use for mental health reasons according to the type of professional seen, and determinants of service use. RESULTS: The rates of depression were similar in Canada (8.2%) and the United States (8.7%). However, U.S. respondents without medical insurance were twice as likely as Canadian respondents and U.S. respondents with medical insurance to meet the criteria for depression. Rates of mental health service use did not differ between Canada (10.1%) and the United States (10.6%). In the United States, medical insurance was not a determinant factor of service use. However, U.S. respondents with no medical insurance were more likely than the other two groups to report an unmet need. Also, among those with depression, U.S. respondents with no medical insurance were less likely to use any type of mental health service (36.5%) than U.S. respondents with medical insurance (55.7%) and Canadians (55.7%). Further, a positive correlation between a mental health need and service use was observed in Canada but not for those without medical insurance in the United States. CONCLUSIONS: There was no difference in the prevalence of depression and mental health service use between Canada and the United States. Among those with depression, however, disparities in treatment seeking were found to be associated with medical insurance in the United States. Both Canada and the United States need to improve access to health services for those with mental disorders, and special attention is needed for those without medical insurance in the United States.     

Treatment and adequacy of treatment of mental disorders among respondents to the Mexico National Comorbidity Survey

OBJECTIVE: This study described the rate and adequacy of mental health service use among participants in the Mexico National Comorbidity Survey and the correlates of any 12-month treatment and of adequate treatment. METHOD: The authors conducted face-to-face household surveys of a probability sample of individuals ages 18 to 65 years in the noninstitutionalized population living in urban areas of Mexico from 2001 to 2002. The use of mental health services and 12-month DSM-IV disorders was assessed with the World Mental Health version of the World Health Organization Composite International Diagnostic Interview. The rates and correlates of any service use and the adequacy of treatment were identified in logistic regression analyses, taking into account the complex sample design and weighting process. RESULTS: The data reported here were based on 2,362 interviews. Fewer than one in five respondents with any psychiatric disorder during the last 12 months used any service during the prior year. The rates of service use by those with mood disorders were somewhat higher. About one in every two respondents who used services received minimally adequate care. CONCLUSIONS: The authors found large unmet needs for mental health services among those with psychiatric disorders. Those with mental illness and those who deliver or seek to improve mental health care in Mexico face enormous challenges.     

Impact of insurance status on access to care and out-of-pocket costs for U.S. individuals with epilepsy

We analyzed data from the 2002–2007 Medical Expenditure Panel Survey (MEPS) to assess whether individuals with epilepsy who are uninsured and those who have Medicaid coverage experience differences in medical resource utilization or out-of-pocket costs compared with those having other types of insurance. With sociodemographic characteristics controlled for, uninsured individuals had significantly fewer outpatient visits, fewer visits with neurologists, and greater antiepileptic drug costs than did those with private insurance. Individuals with Medicaid coverage had similar medical resource utilization rates but lower out-of-pocket costs compared with privately insured individuals. These findings indicate substantial barriers to receipt of appropriate medical care for uninsured individuals with epilepsy, but not for those with Medicaid coverage. Future studies should evaluate whether ongoing changes to the US health care system are able to address the differences in care we found among uninsured individuals with epilepsy and should incorporate measures of disease severity and unmet need.     

Unmet needs for services for older adults with mental illness: comparison of views of different stakeholder groups.

OBJECTIVE: The authors assessed the need for mental health services among older adults in San Diego County, California, by determining what needs were not being addressed by existing services, what services were necessary to address these needs, and how much consensus there was among different stakeholders with respect to the problems and solutions related to service delivery. METHODS: Semistructured interviews were conducted with 23 health care and social service providers and administrators, 16 services consumers and other older adults (55 years of age and older), and 19 caregivers/family members and patient/client advocates. This was followed by four focus groups comprised of 18 providers and administrators, six focus groups comprised of 50 consumers and other older adults, and five focus groups comprised of 39 caregivers (family members and advocates). RESULTS: The unmet needs fell into three categories: mental health services, physical health services, and social services. Two interrelated themes were identified by participants: 1) the need for age-appropriate and culturally appropriate services to overcome barriers to mental health services access, use, and quality; and 2) the interrelations between unmet needs that address prevention as well as treatment of mental illness, including socialization and social support, transportation, housing, and physical health care. Differences in stakeholder assessment of unmet needs were associated with respective roles in delivery and use of mental health services. CONCLUSION: Age-appropriate and culturally appropriate solutions that address both prevention and treatment may represent the best strategies for addressing the challenges of mental illness and are most likely to be endorsed by all three groups of stakeholders.     

Longitudinal patterns of alcohol, drug, and mental health need and care in a national sample of U.S. adults

OBJECTIVE: Use of longitudinal data can help clarify the extent of persistent need for services or persistent problems in gaining access to services. This study examined the level of transient and persistent need and unmet need over time among respondents to a national survey and whether need was met by provision of mental health services or resolved without treatment. METHODS: Data from the longitudinal Health Care for Communities (HCC) household telephone survey were used to produce joint distributions of need status and care for two periods (wave 1 data collected in 1997 to 1998 and wave 2 data collected in 2000 to 2001; N=6,659). Perceived need was measured as self-report of need for help with a mental or substance use problem. Probable clinical need was assessed with the Composite International Diagnostic Interview, the Alcohol Use Disorders Identification Test, and the 12-item Short Form Health Survey. RESULTS: High levels of persistent unmet need for care (44 to 52 percent) were found among respondents who had probable clinical need in wave 1. Although a majority of those with need received some care, an equal proportion (about 30 percent) of those with perceived need only or probable clinical need in wave 1 did not receive any care. A substantial portion of need (22 to 26 percent) appears to have resolved without treatment, which may suggest high levels of transient need. CONCLUSIONS: Persistent patterns of unmet need represent important targets for policy and programs that can improve utilization, including outreach, education, and improved insurance coverage.     

Child and adolescent mental health in South Africa

Mental health problems in childhood and adolescence pose a major threat to public health. Epidemiological studies in high, middle and low income countries indicate that approximately one in five children and adolescents suffer from a mental disorder. In many instances these persist into adulthood. In South Africa, HIV infection, substance use, and exposure to violence increase vulnerability to mental disorders. Child and adolescent mental health services play a key role in reducing the burden of mental disorders in childhood and later in adulthood. This paper focuses on service needs for children and adolescents in South Africa. It commences with a discussion of the prevalence of child and adolescent psychiatric disorders after which the legal and policy context of child and adolescent psychiatric services is described. A framework for child and adolescent mental health service provision is presented, following which steps for reducing the extent of unmet service need are considered. The paper concludes with a call to scale up child and adolescent mental health services in South Africa, based on the stark realities of unmet need and the constitutional rights of children and adolescents to appropriate mental health care.     

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.     

Factors associated with adolescent mental health service need and utilization

OBJECTIVE: To determine the association of parent, family, and adolescent variables with adolescent mental health service need and utilization. METHOD: Correlates of adolescent mental health service utilization, self-perceived need and unmet need were investigated in a general population sample of 1,120 Dutch adolescents aged 11 to 18 years (78% response rate). RESULTS: 3.1% of the sample had been referred for mental health services within the preceding year, and 3.8% reported unmet need. 7.7% of adolescents at risk for psychopathology, and 17.8% of those indicating a need for help, had been referred. Family stress and adolescent's self-reported problems were most strongly associated with service need and utilization. Internalizing problems, female gender, and low education level were associated with self-perceived unmet need. Adolescent ethnicity and competence in activities and school were associated with service use, but did not influence service need, while the opposite effect was found for adolescent age and parental psychopathology. CONCLUSION: In designing intervention programs aimed at increasing adolescent mental health service use, distinctions should be made between efforts focused at adolescents not recognizing their problems, and those with unmet need.     

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.     

Modeling the social determinants of caregiver burden among families of children with developmental disabilities

This study described predictors of caregiver burden among parents of children with developmental disabilities. The sample, obtained from the 2005-2006 National Survey of Children With Special Health Care Needs, included 12,225 children, aged 5 to 17 years, with a developmental disability. Structural equation modeling assessed the relationships between the factors of Caregiver Burden, Ease of Accessing and Navigating the Health Care System, and Unmet Health Care Needs. Caregiver burden was inversely associated with ease of accessing and navigating the health care system (β = -0.094, SE (β) = 0.045) and positively associated with unmet health care needs (β = 0.428, SE (β) = 0.036). Parents of poor, minority, and uninsured children experienced significantly greater caregiver burden. Bolstering services, particularly for vulnerable families, may ameliorate caregiver burden.     

Relationship between entry into child welfare and mental health service use

OBJECTIVE: This study examined the relationship between initiation of outpatient mental health service use and level of child welfare involvement. METHODS: Three levels of child welfare involvement were examined: in-home care and no child welfare services beyond an initial investigation, in-home care and additional child welfare services, and placement in out-of-home care (foster care). Longitudinal data were collected for a subsample of children (N=3,592) aged two through 14 years who were enrolled in the National Survey of Child and Adolescent Well-Being, a nationally representative sample of children undergoing investigation for abuse or neglect. Event history analysis was used to model relative risk of initiation of mental health service use over time. RESULTS: Hazard functions revealed a large increase in onset of mental health services immediately after the time of the initial contact with child welfare, varying by level of child welfare involvement and leveling off by three months after the initial contact. The multivariate Cox proportional-hazards model indicated that compared with children who were placed in out-of-home care, those in in-home care who did not receive any further child welfare services were about one-third as likely to use mental health services and those in in-home care who received additional child welfare services were one-half as likely to use mental health services. Other covariates in the model predicted mental health service use, including being older, being Caucasian, having a history of maltreatment (specifically, physical abuse, physical neglect, or abandonment), being uninsured, and need for mental health services, as measured by the Child Behavior Checklist. CONCLUSIONS: Contact with child welfare functions as a gateway into mental health services for children in child welfare, even when need for such services is controlled for.     

Perceived unmet need for mental health care for Canadians with co-occurring mental and substance use disorders

OBJECTIVE: Previous analyses demonstrated an elevated occurrence of perceived unmet need for mental health care among persons with co-occurring mental and substance use disorders in comparison with those with either disorder. This study built on previous work to examine these associations and underlying reasons in more detail. METHODS: Secondary data analyses were performed on a subset of respondents to the 2002 Canadian Community Health Survey (unweighted N=4,052). Diagnostic algorithms classified respondents by past-year substance dependence and selected mood and anxiety disorders. Logistic regressions examined the associations between diagnoses and unmet need in the previous year, accounting for recent service use and potential predisposing, enabling, and need factors often associated with help seeking. Self-reported reasons underlying unmet need were also tabulated across diagnostic groups. RESULTS: Of persons with a disorder, 22% reported a 12-month unmet need for care. With controls for service use and other potential confounders, the odds of unmet need were significantly elevated among persons with co-occurring disorders (adjusted odds ratio=3.25; 95% confidence interval=1.96-5.37). Most commonly, the underlying reason involved a preference to self-manage symptoms or not getting around to seeking care, with some variation by diagnosis. CONCLUSIONS: The findings highlight potential problems for individuals with mental and substance use disorders in accessing services. The elevated occurrence of perceived unmet need appeared to be relatively less affected by contact with the health care system than by generalized distress and problem severity. Issues such as stigma, motivation, and satisfaction with past services may influence help-seeking patterns and perceptions of unmet need and should be examined in future work.     

Mental health needs of the uninsured

As many as 37 million Americans have no medical insurance, but no data exist on the mental health needs of community samples of the uninsured. Using interview data from a household sample in Los Angeles, we found that the uninsured had a higher prevalence of serious psychiatric disorder (16%) than those with private health insurance (12%), but had a prevalence similar to those with Medicaid (18%). Access to mental health services among those with a psychiatric disorder was similar in the uninsured (14.5%) and those with private insurance (18%) but was less than those with Medicaid coverage (42%). These results indicate that the uninsured have a great potential need for mental health services and that access might be improved through insurance plans such as Medicaid. However, further study is needed to determine the adequacy and quality of services provided under Medicaid and whether such a plan would improve access for an uninsured population such as the one studied here.