Clinical characteristics and service use of persons with mental illness living in an intermediate care facility.

OBJECTIVE: The study examined the characteristics of residents living in a 450-bed intermediate care facility for persons with severe mental illness in Illinois and sought to determine the factors predicting their utilization of mental health services. METHODS: Data on 100 randomly selected residents with a chart diagnosis of schizophrenia were collected using chart review and interviews. Data for 78 residents whose diagnosis of schizophrenia or schizoaffective disorder was confirmed using the Structured Clinical Interview for DSM-IV were included in the analyses. RESULTS: Fifty-three percent of the residents used facility-based specialty mental health services beyond medication management, such as group therapy or a day program. Persons with the least severe psychiatric illnesses and with higher levels of motivation for overall care used the most mental health services. Thirty-five percent of the residents had been discharged to an inpatient psychiatric unit during the previous year. Residents most likely to be discharged to those settings were young men with a history of homelessness who refused facility-based health services. CONCLUSIONS: Despite recent policy-driven efforts to improve care in this intermediate care facility for persons with mental illness, the facility continues to have problems addressing the mental health needs of the residents.     

Prevalence and course of psychiatric disorders among nursing home admissions

Several studies have shown that psychiatric disorders are common in nursing homes, but information on the course of psychiatric morbidity shortly after admission is still lacking. Therefore, we interviewed 262 residents of Austrian nursing homes within 2 weeks following admission, and a second time after 6 months. Using the Clinical Interview Schedule and its case criteria, prevalence was 76.3% at admission, and 69.9% 6 months later. In the intervening period, the mortality rate was markedly higher among psychiatric cases, and the incidence of new psychiatric cases (5.9%) was slightly lower than the rate of remission (8.6%). At both assessments, organic mental illness was the most frequent diagnosis. Nursing home residents suffering from psychiatric disorders were treated predominantly by general practitioners applying a psychotropic drug regimen. Accepted: 11 March 1997     

Use of PASRR programs to assess serious mental illness and service access in nursing homes

OBJECTIVE: This study assessed the implementation of state Preadmission Screening and Resident Review (PASRR) programs with respect to identification of serious mental illness among nursing facility applicants and residents and access to mental health services. METHODS: A national survey was conducted with representatives from agencies that implement PASRR in all 50 states and the District of Columbia. Also, 44 states sent PASRR data for review. Four states were selected for an in-depth study; six nursing homes per state were selected and one staff member from each facility was interviewed (N=24). Medical records were reviewed for 30 to 40 residents from each facility who met criteria for potentially having a disabling serious mental illness (N=786). RESULTS: Medical records showed that 50 percent of patients at the time of admission and 68 percent of patients at the time of the record review had a psychiatric diagnosis, typically a diagnosis of depressive disorder. At the time of admission, fewer records identified individuals with a serious mental illness (9 to 20 percent) or a primary diagnosis of any psychiatric illness (5 to 12 percent). Many records indicated that in-depth, required PASRR screens were not performed. Ninety percent of the states reported that Medicaid covers only basic psychiatric consultation services, such as medication monitoring, in nursing facilities. Between 30 and 32 percent of national survey respondents also characterized access to facilities that provide mental health services as limited and of variable quality. Although all 24 nursing facilities reported providing psychiatric consultation services, access to other mental health services, such as psychosocial rehabilitation or individual counseling, varied considerably. CONCLUSIONS: Nursing facility compliance with administration and documentation of PASRR screens appears problematic. Nevertheless, there do not appear to be excessively high numbers of residents with serious mental illness, suggesting that state PASRR programs may contribute positively to the identification of people with serious mental illness. However, many nursing facility residents have some type of psychiatric illness, and PASRR legislation does not appear to have enhanced their ability to gain access to mental health services beyond standard psychiatric consultation and medication therapy.     

Mental health problems in elderly people with and without Down's syndrome

ABSTRACT. This article reports on age-specific findings of mental health problems among residents with Down's syndrome (DS) (n=307) and without (non-DS) (n=1274 in dutch group homes and institutes for people with mental retardation. Whereas a proportional increase of psychological problems was found for elderly DS persons with severe mental retardation, non-DS residents did not show such age-specific differences. High ratings of psychological problems for the elderly DS residents corresponded very well with the diagnosis of 'dementia' made by the physicians. Only for non-DS persons with severe mental retardation was a proportional decrease of challenging behaviour found with advanced age. Whereas psychological problems in elderly DS persons could be explained for the greater part of the diagnosis 'dementia', challenging behaviour-although also common in elderly DS-was shown to be a more independent phenomenon. With regard to psychiatric diagnosis, non-DS residents with mild retardation had six times as much a mental disorder, and non-DS residents with severe or profound mental retardation had up to 15 times as much, compared with their DS peers.     

Health care needs and residential settings: A national survey and policy perspectives

The relationship between health care needs and residential service placement among older persons with mental retardation is explored. Findings from the 1985–86 Center for Residential and Community Services (CRCS) study of persons over the age of 62 living in residential facilities owned, operated and/or licensed by developmental disabilities agencies are presented. A 10 per cent sample of facilities with one or more persons over the age of 62 was selected, including foster care, group homes, large private facilities (16 or more residents) and state institutions. The final sample consisted of 370 residents in 235 facilities, with an average age of 70 years. Information about the residents was completed by direct careproviders who knew the residents well. For purposes of comparison, findings about persons with mental retardation living in nursing homes and older persons in general living in the community are also presented.

The findings highlight the importance of using the older population in general as a referent, as well as challenging the assumption of medical need among the vast majority of persons residing in nursing facilities. Many of the changes found in the older population of persons with mental retardation were similar to those noted for older persons in general, and there was considerable overlap in the characteristics of persons with mental retardation living in nursing homes and residents of facilities operated by developmental disabilities agencies. Many of the differences found between persons living in community residential facilities and persons living in state institutions and/or nursing homes were in areas such as level of retardation and independent living skills, which may increase assistance needs, but which do not necessarily increase the need for medically intensive services. Greater system flexibility is needed in order for this group to remain successfully in the community.     

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

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

Shared decision-making preferences of people with severe mental illness

OBJECTIVE: Perceived roles and preferences were explored for shared decision making among persons with severe mental illnesses. METHODS: In this pilot study, 30 adult clients with severe mental illness in a community mental health center were surveyed about decision making regarding psychiatric medications, rehabilitation, and general medical care. RESULTS: Clients generally expressed a desire for greater participation in decisions about psychiatric care than they currently experienced. Regarding use of new psychiatric medications, 23 persons (77%) preferred autonomous or shared roles, but only 11 (37%) rated their current roles as more than passive (z=-2.83, p=.005). Clients were less likely to prefer a passive role in medication decisions about psychiatric care than about general medical care (seven persons, or 23%, versus 23 persons, or 77%; z=-3.01, p=.003). CONCLUSIONS: Most clients with severe mental illnesses prefer shared decision making, particularly in relation to their mental health care.     

An estimation of the impact of OBRA-87 on nursing home care in the United States.

The Omnibus Budget Reconciliation Act of 1987 (OBRA-87) established criteria for Medicare- or Medicaid-certified nursing homes to use in admitting or retaining mentally ill patients. In effect, the law created five dispositional categories for residents or potential residents of nursing homes. Using data from the 1985 National Nursing Home Survey conducted by the National Center for Health Statistics, the authors estimate what proportion of nursing home residents would fall into each of the categories. They suggest that the initial impact of the law will be to shift costs from federal programs to the states. Nursing homes will be expected to provide more mental health services. In the absence of other services, the regulations have a high potential for creating homelessness and continuing a pattern of failure to adequately serve patients with serious mental illness.     

Hospital outcome measures following assertive community treatment in Edmonton, Alberta.

OBJECTIVE: To examine hospital outcome measures for individuals with chronic and severe mental illnesses before and after their registration in an assertive community treatment (ACT) program in Edmonton, Alberta. METHODS: Data were collected from Alberta Health on individuals who were registered in ACT from April 1993 to April 1995. For each individual, hospital outcome measures were calculated for the 365 days prior to and 365 days after registration for ACT (thus covering April 1, 1992-March 31, 1996). RESULTS: Data were collected from 295 individuals. Compared with 1 year prior to beginning ACT, there was a 34% reduction in hospital separations for patients with psychiatric diagnoses. The average length of stay (LOS) for each separated patient decreased by 56%, and the hospitalization days for each patient separated also decreased by 39%. The number of emergency visits for psychiatric reasons was reduced by 32%, and the number of clients visiting emergency departments for psychiatric reasons declined by 30%. CONCLUSIONS: In the 1-year period after registration in an ACT program, hospital outcome measures were improved in this cohort of 295 individuals with severe and chronic mental illnesses.     

The effect of housing interventions on neuropsychological functioning among homeless persons with mental illness

The authors tested the hypotheses that neuropsychological functioning would improve after homeless persons with severe and persistent mental illness were provided with housing and that executive functioning would improve more among those placed in group homes than among those placed in independent apartments. A total of 114 persons with serious and persistent mental illness who were stable residents of homeless shelters completed neuropsychological testing and were randomly assigned to group homes or independent apartments; 91 participants (52 assigned to group homes and 39 assigned to independent apartments) were retested after 18 months. Overall neuropsychological functioning improved significantly across the full study sample. Executive performance, measured by the Wisconsin Card Sorting Test, decreased significantly among persons assigned to independent apartments and increased, but not significantly, among those assigned to group homes. The findings suggest that providing housing for persons who have severe and persistent mental illness improves cognitive functioning but that independent living may diminish executive functioning.     

Prevalence of psychiatric disorders among National Health Insurance enrollees in Taiwan

OBJECTIVE: About 96 percent of all residents of Taiwan were enrolled in the National Health Insurance (NHI) program in 2000. This study used claims data from the NHI database to determine the prevalence of and the demographic characteristics that are associated with psychiatric disorders. METHODS: A total of 200,432 persons, about 1 percent of Taiwan's population, were randomly selected from the NHI database. Persons under the age of 18 years and persons who were not eligible for NHI in 2000 were excluded, leaving 137,914 persons available for this study. Data for enrollees who had at least one service claim during 2000 for ambulatory or inpatient care for a principal diagnosis of a psychiatric disorder were classified into one of the psychiatric disorder categories according to ICD-9-CM diagnostic criteria. Data from the 2000 NHI study were compared with data from a 1985 community survey, the Taiwan Psychiatric Epidemiological Project, to determine how the prevalence of psychiatric disorders changed over the 15-year period. RESULTS: The one-year prevalence of any major psychiatric disorder, any minor psychiatric disorder, and any psychiatric disorder were 1.37 percent, 4.26 percent, and 5.30 percent, respectively. The differences in prevalence between the sexes were significant for five major and nine minor psychiatric disorders. The prevalence for eight psychiatric disorders were lower in the 2000 NHI study than in the 1985 community survey. However, the prevalence of schizophrenic disorder was found to be higher in the 2000 study and the prevalence of bipolar disorder was found to be the same in both studies. CONCLUSIONS: Because the prevalence of psychiatric disorders were generally lower in this study and in the 1985 community survey than those in other countries, it was concluded that both major and minor psychiatric disorders were undertreated in Taiwan. It is necessary for the public health department and the general population to emphasize mental illness education, prevention, and treatment in Taiwan.     

Racial differences in the prevalence of dementia among patients admitted to nursing homes

OBJECTIVE: The purpose of this study was to determine the prevalence of dementia among black and white residents on admission to nursing homes and to determine whether demographic and health characteristics known to be associated with dementia were correlated with dementia in this population. METHODS: Data from medical records and structured interviews with family members, nursing staff, and nursing home residents were gathered for 2,285 persons newly admitted to nursing homes in Maryland from 1992 to 1995. A stratified sample of 59 nursing homes was used. An expert panel of five physicians classified each resident as demented, nondemented, or indeterminate. Associations between dementia status, race, and selected characteristics were examined. RESULTS: Black residents (77 percent) were significantly more likely than white residents (57 percent) to be classified as demented. Older age was associated with dementia in both races. Less education, male gender, and a history of a cerebrovascular accident were associated with an increased prevalence of dementia among white residents only. After demographic and health characteristics associated with dementia were controlled for, black race remained independently associated with a diagnosis of dementia. CONCLUSIONS: The rate of dementia on admission to nursing homes was higher among black residents than among white residents, a finding that has implications for the delivery of care. The higher rate may be due to psychosocial factors operating differently in blacks and whites that influence the timing of admission to a nursing home.     

The development of psychiatric care after the mental health care reform in Sweden. A case register study

A process of deinstitutionalization and a series of mental health care reforms targeting severely mentally ill persons have taken place worldwide. The objective of this study was to follow-up the volume of psychiatric care after the 1995 Swedish reform and to study if the intended efforts of the reform were fulfilled. In a municipality, during the time-period 1994–2003, the development of number of days of inpatient care, inpatient care episodes, visits to outpatient facilities and the number of unique patients were studied using case registers. The number of persons staying in group homes and nursery homes was also studied. The number of days of inpatient care for persons given a diagnosis of schizophrenia was drastically reduced, but this reduction was quantitatively substituted by the persons staying in different kind of group homes. The implementation of new psychiatric field teams directed towards persons with psychosis and new social service field teams targeting this same group were reflected in the registers. Data supported that the intended efforts of the mental health care reform were in fact carried out, but the prioritizing of the target group of the reform may have influenced the care of persons with other kinds of psychiatric problems negatively.     

The development of psychiatric care after the mental health care reform in Sweden. A case register study

A process of deinstitutionalization and a series of mental health care reforms targeting severely mentally ill persons have taken place worldwide. The objective of this study was to follow-up the volume of psychiatric care after the 1995 Swedish reform and to study if the intended efforts of the reform were fulfilled. In a municipality, during the time-period 1994-2003, the development of number of days of inpatient care, inpatient care episodes, visits to outpatient facilities and the number of unique patients were studied using case registers. The number of persons staying in group homes and nursery homes was also studied. The number of days of inpatient care for persons given a diagnosis of schizophrenia was drastically reduced, but this reduction was quantitatively substituted by the persons staying in different kind of group homes. The implementation of new psychiatric field teams directed towards persons with psychosis and new social service field teams targeting this same group were reflected in the registers. Data supported that the intended efforts of the mental health care reform were in fact carried out, but the prioritizing of the target group of the reform may have influenced the care of persons with other kinds of psychiatric problems negatively.     

Involvement in the child welfare system among mothers with serious mental illness

OBJECTIVE: This study sought to determine the association between maternal schizophrenia and major affective disorders (serious mental illness) and child custody arrangements in a sample of Medicaid-eligible mothers. METHODS: Medicaid eligibility and claims data were merged with data from the child welfare system in Philadelphia for 1995 to 2000. The sample comprised 4,827 female residents of Philadelphia between the ages of 15 and 45 as of 1996, who were initially eligible for Medicaid through Aid to Families With Dependent Children between 1995 and 1996 and who had at least one family member younger than 18 years at the beginning of the study period. Logistic regression was used to determine association between maternal mental illness and involvement in the child welfare system. RESULTS: Among the 4,827 mothers, 7.2 percent had a serious mental illness and 4.4 percent had other psychiatric diagnoses. More than 14 percent of mothers with serious mental illness received child welfare services, compared with 10.8 percent of those with other psychiatric diagnoses, and 4.2 percent of those without a diagnosis. After the analyses adjusted for a past inpatient episode, race or ethnicity, and age, mothers with serious mental illness were almost three times as likely to have had involvement in the child welfare system or to have children who had an out-of-home placement. CONCLUSIONS: The results suggest the urgent need for increased planning and coordination between the child welfare and mental health systems, including provision of parenting support as part of mental health treatment for mothers.     

The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: a randomized clinical trial

OBJECTIVES: To examine the effect of integrated emotion-oriented care on nursing home residents with dementia and nursing assistants. DESIGN: A multi-site randomized clinical trial with matched groups, and measurements at baseline and after seven months. SETTING: Sixteen psychogeriatric wards in fourteen nursing homes in the Netherlands. PARTICIPANTS: One hundred and forty-six elderly residents with the diagnosis dementia of the Alzheimer (DAT) type, mixed DAT and vascular dementia, and dementia syndrome (NAO) and 99 nursing assistants. INTERVENTIONS: Integrated emotion-oriented care and usual care. MESUREMENTS: Demented elderly: Behaviour and mood related to adaptation to the illness and the institutionalization. Nursing assistants: General health as measured by feelings of stress, stress reactions, feeling of competence and illness. RESULTS: Positive effects in favour of the integrated emotion-oriented care were found in mild to moderately demented residents on two adaptive tasks: maintaining an emotional balance (less anxiety) and preserving a positive self-image (less dissatisfaction). In the trained group of nursing assistants fewer stress reactions were found only in those who perceived improvement in their emotion-oriented care skills after training. CONCLUSION: Emotion-oriented care is more effective with regard to the emotional adaptation in nursing homes of persons with a mild to moderate dementia. For the severely demented elderly we did not find this surplus value. This outcome is of clinical importance for elderly persons with dementia who are cared for in nursing homes. With respect to the nursing assistants it is concluded that emotion-oriented care has a positive influence on stress reactions in some of them.     

Use of general medical services by VA patients with psychiatric disorders

OBJECTIVE: Patients with psychiatric disorders, particularly those with severe mental illnesses, have high rates of undetected and untreated medical problems and substantially elevated mortality rates due to medical illness. The authors sought to develop a better understanding of the demographic, medical, and psychiatric characteristics of this population to inform efforts to improve the medical care of these persons. METHODS: Using Department of Veterans Affairs (VA) databases, the authors examined use of medical services by 175,653 patients who were treated in Southern California and Nevada during fiscal year 2000. Multivariate regression models were used to examine factors affecting receipt of any medical care and the number of medical visits. RESULTS: Patients with psychiatric diagnoses had fewer medical visits than other VA patients; the largest differences were seen for patients with severe mental illnesses. Patients who were younger and male had few visits. Patients with diabetes or hypertension who had been diagnosed as having schizophrenia, bipolar disorder, or an anxiety disorder had substantially fewer visits than those who did not have these psychiatric diagnoses. Patients older than 50 years were less likely to have any medical care if they had a diagnosis of a substance use, depressive, bipolar, or anxiety disorder or posttraumatic stress disorder. CONCLUSIONS: Use of medical care varies by psychiatric diagnosis. Young adults with schizophrenia and posttraumatic stress disorder and adults of all ages with bipolar disorder have an especially high risk of not receiving general medical services. Interventions to improve medical care may need to be tailored to the population being targeted.     

Outpatient commitment: what, why, and for whom

The authors describe studies showing the effectiveness of involuntary outpatient commitment in improving treatment compliance, reducing hospital readmission, and reducing episodes of violence among persons with severe psychiatric illnesses. They point out that because of its role in enhancing compliance with treatment, outpatient commitment can be regarded as a form of assisted treatment, such as assertive case management, representative payeeship, and mental health courts. The authors argue that such assisted treatment is necessary for persons with severe psychiatric illnesses who are noncompliant with their medication regimens because many lack awareness of their illnesses because of biologically based cognitive deficits. They recommend outpatient commitment for any individual with a severe psychiatric disorder who has impaired awareness of his or her illness and is at risk of becoming homeless, incarcerated, or violent or of committing suicide, and they provide case examples. The authors conclude by addressing eight of the most common objections to outpatient commitment by mental health professionals and civil liberties groups that oppose outpatient commitment.     

Comparison of users and non-users of mental health services among depressed, older, urban African Americans.

OBJECTIVE: The authors sought to determine differences between depressed older black residents in an urban community who do and do not use formal mental health services. METHODS: The Treatment Group (TG) consisted of 106 black patients age >or=55 with a diagnosis of depression who were recruited from outpatient psychiatric programs in Brooklyn, NY. The Untreated Community Group (UCG) consisted of 101 cognitively intact black subjects age >or=55 from randomly selected block groups in Brooklyn who met symptom criteria for major or minor depression and had no previous history of psychiatric treatment. RESULTS: In logistic regression analysis, TG persons were significantly more likely than the UCG persons to be female, younger, born in the United States, to have impaired daily functioning, have a family history of mental illness, and believe that environmental factors and religious activities could influence mental illness. TG persons were significantly less likely to have social network members who provided advice, to use spiritualists or their products, to have vision or hearing impairments, and to have depressive symptoms. Although most UCG persons visited their doctor at least three times annually, only 11% reported using these physicians for help with mental health problems. CONCLUSIONS: A combination of demographic and attitudinal factors, family psychiatric history, social supports, and functional impairments were associated with the use of mental health services. Despite reluctance of persons in the UCG to use primary-care physicians for mental health reasons, the latter remain the most feasible intervention point within the existing service system.     

Treatment prospects for persons with severe mental illness in an urban county jail

OBJECTIVE: A retrospective study of inmates with severe mental illness in a large, urban county jail aimed to obtain information about their psychiatric and criminal histories and status, the psychiatric services they used while incarcerated, and the challenges they might present in psychiatric treatment after release. METHODS: The authors ascertained demographic characteristics, diagnoses, psychiatric and legal histories, and current psychiatric condition and treatment from jail psychiatric records of a random sample of 104 male inmates with mental illness and from electronic county mental health records and state records of criminal histories. RESULTS: Seventy-eight inmates (75%) were diagnosed as having a severe mental illness. Of these, 59 (76%) required inpatient care or its equivalent for part of their time in jail for the current offense. Of the inmates with severe mental illness, 92% had a history of nonadherence to medications before this arrest, 95% had prior arrests, 72% had prior arrests for violent crimes against persons, and 76% were known to have a history of substance abuse. CONCLUSIONS: A large percentage of persons with severe mental illness received their acute psychiatric inpatient treatment in the criminal justice system rather than in the mental health system. The persons with severe mental illness in this study would present a major challenge in treatment in any setting given their psychiatric and criminal histories. The resources of the mental health system need to be greatly expanded, with priority given to treating persons who are criminalized or who are in danger of becoming criminalized.