Health maintenance organizations and persons with severe mental illness

Many if not most scenarios for reform of the U.S. health care system imply that health maintenance organizations (HMOs) will continue their rapid growth. Some advocates argue that a comprehensive health care system should offer services to the severely mentally ill on the same basis as the physically ill. Others note that severe mental illness has traditionally been addressed by a separate, social service system which, for all its deficiencies, has at least provided some level of care. Still others contend that allowing severely mentally ill persons barrier free access to health care would be prohibitively expensive. Inspired by this debate the author reviews our knowledge about HMOs and persons with severe mental illness. It is argued that workers in community mental health programs need to understand HMOs and their potential contribution to providing services for persons with severe mental illness.Supported in part by NIMH grant number R01 MH45015. A reviewer's thoughtful comments are gratefully acknowledged.     

Community mental health care in India

Recent times are witnessing methods in the various forms of community care for the mentally ill in India. Non-governmental organizations (NGO) play a pivotal role in filling the gap in the existing mental health services in India and the substantial need for these services. Various strategies that have been employed in community care have attempted to utilize existing community resources for implementation. Informal manpower resources incorporated with specialist psychiatric care and integrated with existing health care facilities have been general strategies. While the feasibility and cost-effectiveness of the NGO operated community outreach programs for the mentally ill have been demonstrated, various factors are seen to influence the planning and execution of such programs. This paper elucidates some critical factors that would need to be considered in community mental health care in India.     

Health care utilization by persons with severe and persistent mental illness

Claims for physical health care among 220 Medicaid enrollees with severe mental illness and 166 Medicaid enrollees who were not enrolled in the public mental health system were compared. Claims for the mentally ill group were 18 percent less than for the group without severe mental illness. Twenty-eight percent of claims for mentally ill patients were for treatment in emergency rooms and ambulances, compared with 11 percent for patients without mental illness; 26 percent of claims for patients without mental illness were for care in outpatient surgical and outpatient hospital settings, compared with 14 percent for mentally ill patients. Results suggest inefficient use of the health care system by mentally ill patients and highlight the need for coordination of care.     

Beliefs about mental illness and willingness to seek help: a cross-sectional study

Evidence indicates that older adults underutilize mental health services, but little is known empirically about the perceptions older adults have about mental illness and their attitudes about seeking professional help for psychological problems. The present study examined beliefs about mental illness and willingness to seek professional help among younger (n=96; M age=20.6 years; range=17-26 years) and older (n=79; M age=75.1 years; range=60-95 years) persons. Participants completed the Beliefs Toward Mental Illness Scale and the Willingness to Seek Help Questionnaire. Older adults had generally similar perceptions of mental illness as younger adults except that older adults were more likely to perceive the mentally ill as being embarrassing and having poor social skills. Older adults also did not report a lower willingness to seek psychological help. Correlational analyses showed that, among older adults, increases in negative attitudes about mental illness (specifically, the view that the mentally ill have poor interpersonal skills) are associated with decreases in willingness to seek psychological services. An implication is that negative stereotypes about mental illness held by some older adults could play a role in their underutilization of mental health services. Other barriers to mental health care are also discussed.     

Planning mental health services for chronic patients.

At the present time, deinstitutionalized services for the chronically mentally ill are less than satisfactory. If planning for the future is to reverse the trend of incomplete service delivery for this population, it must start with the recognition and application of certain fundamental concepts. Effective planning requires idealism, vision, and a sense of reality. Six separate but interrelated dimensions of reality must be taken into account: the need for mental hospital; the importance of precise planning goals; the unique service needs of the chronically mentally ill; the need for interagency planning; the importance of a functioning and sensitive patient tracking system; and appreciation of the attitudinal structure within which services are delivered. Wherever the chronically mentally ill live, whether in the hospital or in the community, their requirements must be made the primary focus in mental health planning.     

Changes in public attitudes towards mental illness in the Athens area (1979/1980-1994)

Opinions about mental illness were measured, in 1994, in a probability sample consisting of 360 residents of two boroughs in greater Athens. These boroughs represent the catchment area of a community mental health centre. The aim of this study was to compare the differences in attitudes towards mental illness with a matched sample of 360 respondents drawn from the sample of the 1979/1980 attitudinal study, conducted in the same area. The instrument used was the Opinion about Mental Illness scale, which yields five factors. In all five factors statistically significant differences between the two samples were observed. The recent study sample expressed more positive attitudes towards the social integration of the mentally ill, and did not favour the social discrimination against and restriction of mental patients. These results could be explained in the context of a positive and tolerant social climate in the Athens area, strengthened by the implementation of local community mental health intervention programmes.     

Familiarity with mental illness and approval of structural discrimination against psychiatric patients in Germany

Structural discrimination against psychiatric patients may occur as a result of distribution of resources in the health system. We examine whether familiarity with mental illness, which reduces discrimination on the individual level, also moderates the approval of structural discrimination in health care funding. We conducted a representative survey of the German population (N=5025) in 2001 using a fully structured personal interview, including a measure of preferences for the allocation of health resources and an assessment of familiarity with mental illness. The approval of structural discrimination was inversely related to the individual's familiarity with mental illness in depression and, to a lesser extent, in schizophrenia. This relationship was absent for alcoholism and generally weak for contacts to mentally ill persons outside one's own family. Strategies successful in reducing individual discrimination are thus not necessarily suitable for combating structural discrimination and need to be tailored to their specific target.     

Characteristics of seriously mentally ill adults in a public mental health system

To aid in planning mental health services, the state of Michigan collected sociodemographic and clinical information on a sample of 2,447 mental health system clientele in both hospital and community settings. Hospitalized patients were found to have poorer functioning and higher levels of disability than clients treated in community settings. Younger patients were more likely to be male, to exhibit more self-destructive behaviors, and to be more aggressive and demoralized. Older patients were more likely to be women, to have a high degree of physical health care needs, and to possess poor skills in self-care and community living. The heterogeneous nature of the population and the presence of complicating problems not traditionally served by mental health systems, such as medical illness and substance abuse, point to a need for interagency planning to address the needs of seriously mentally ill adults.     

Community attitudes and social distance towards the mentally ill in South Sudan: a survey from a post-conflict setting with no mental health services

Purpose

This study investigates attitudes and social distance towards the mentally ill in a post-conflict, low-income country.

Methods

A cross-sectional community survey (n = 1,200) was conducted in South Sudan. Associations between various sociodemographic variables and attitudes toward/social distance from the mentally ill were investigated.

Results

The regression analysis showed that lower levels of education were positively associated with social distance, and Christian or Muslim beliefs, compared with traditional beliefs, were negatively associated with social distance. Familiarity with mental illness or psychological distress was not significantly associated with social distance. Participants who endorsed community-oriented attitudes (rather than hospital/drug-oriented attitudes) about health care for the mentally ill were more likely show a decreased social distance. Participants who believed that the mentally ill were dangerous had higher scores on the social distance scale.

Conclusions

A high level of stigma towards the mentally ill exists in South Sudan, especially in the rural areas. Alongside efforts to build up mental health services in South Sudan, the existing stigma needs to be addressed. Information regarding the role of the community both in preventing mental illnesses and in service delivery should be prioritised.     

Increasing medicaid collections: A mental health center success

Community mental health centers serving chronically mentally ill clients need to take advantage of such special health care financing mechanisms as Medicaid. However, considerable obstacles exist for clients attempting to apply for benefits and for centers attempting to collect for services rendered. This article describes how one center created a system that assists clients with Medicaid applications and assures that all appropriate billing for services occurs. The result was a four-fold return on its investment in the planning and implementation of the system.Judith L. Messal, M.A., is Chief of Staff Development and Training at the Colorado Division of Mental Health. She has worked in community mental health administration for nine years. Sandra K. Karpuk, B.S., is a graduate student in the School of Business Administration at the University of Colorado. She has worked in educational and community mental health administration for seven years.     

Evaluation of care for the disabled mentally ill: Theoretical issues

Summary A precondition for the discharge from an institution of the chronically disabled mentally ill is the availability of adequate alternative facilities and services, optimally meeting their social and mental health needs and allowing as much quality of life as possible at the lowest possible cost. Only a few studies have found alternative care to lead to better outcomes than treatment in good-quality hospitals with respect to illness course and social disablement. Therefore, it is an important question whether extramural care and of what type is better and possibly less expensive than traditional inpatient treatment and for which patients. Health data collected at the national and regional levels provide a basis for continuous monitoring of utilization of services. Such data, however, usually have the limitation of being aggregate in nature and not including contacts with social services. These deficits can be avoided by using cumulative case registers, recording if possible all contacts of the socially disabled mentally ill with intramural and extramural mental health and social services and covering a defined catchment area. Because the disabled mentally ill, depending on their own resources and those of their family and the community at large, have basic needs differing in each individual case, as well as various specific needs determined by the illness which they cannot meet on their own, it is necessary to provide a variety of facilities and services and to coordinate their work. Evaluation and cost-effectiveness investigations of complex packages of care yield generalizable results only if the forms of care under study are defined precisely enough. A precondition of a satisfactory causal analysis of the effectiveness of care programmes and services is sufficient external and internal validity and the use of a design allowing all relevant intervening variables to be controlled for. Because of the problems posed by quasiexperimental designs and controlled case studies in the evaluation of the care of the chronically mentally ill, an observation design will be discussed that allows a more or less reliable analysis of cause and effect, thanks to the inclusion of relevant intervening variables and the partialling out of their effects on outcome. In the evaluation of community services for the disabled mentally ill, it must be taken into account that outcome and costs depend on the system aspect in as much as during the transition from intramural to extramural care severely disabled patients with a greater need of care, consequently producing higher costs, are discharged from hospital to community care in increasing numbers.     

Primary health care in the CMHC: a role for the nurse practitioner.

Although persons with chronic mental illness have a high incidence of physical health problems, they are often ill equipped to seek care within complex health care systems and tend to depend on community mental health centers as their only source of regular health care. The authors describe a role for the nurse practitioner in assessing the medical needs of chronic mentally ill outpatients at a community mental health center and in devising strategies to meet those needs. The nurse practitioner's activities include direct physical health screening and treatment, referral for specialized medical services, consultation, research, and staff and patient education.     

Homelessness in schizophrenia

The impact of mental illness, comorbid substance abuse, and medication nonadherence, coupled with disjointed psychiatric and social services, conspires to a disproportionately high rate of psychiatric disorders among people who are homeless in the United States. This article reviews the prevalence of homeless among the mentally ill as well as the prevalence of mental illness among the homeless and details barriers in access to care and the solutions that have been attempted. The need and solutions to introduce a new generation of physicians and allied health care workers to the unique health care needs of the homeless population are highlighted.     

India mental health country profile

India, the second most populated country of the world with a population of 1.027 billion, is a country of contrasts. It is characterized as one of the world's largest industrial nations, yet most of the negative characteristics of poor and developing countries define India too. The population is predominantly rural, and 36% of people still live below poverty line. There is a continuous migration of rural people into urban slums creating major health and economic problems. India is one of the pioneer countries in health services planning with a focus on primary health care. Improvement in the health status of the population has been one of the major thrust areas for social development programmes in the country. However, only a small percentage of the total annual budget is spent on health. Mental health is part of the general health services, and carries no separate budget. The National Mental Health Programme serves practically as the mental health policy. Recently, there was an eight-fold increase in budget allocation for the National Mental Health Programme for the Tenth Five-Year Plan (2002-2007). India is a multicultural traditional society where people visit religious and traditional healers for general and mental health related problems. However, wherever modern health services are available, people do come forward. India has a number of public policy and judicial enactments, which may impact on mental health. These have tried to address the issues of stigma attached to the mental illnesses and the rights of mentally ill people in society. A large number of epidemiological surveys done in India on mental disorders have demonstrated the prevalence of mental morbidity in rural and urban areas of the country; these rates are comparable to global rates. Although India is well placed as far as trained manpower in general health services is concerned, the mental health trained personnel are quite limited, and these are mostly based in urban areas. Considering this, development of mental health services has been linked with general health services and primary health care. Training opportunities for various kinds of mental health personnel are gradually increasing in various academic institutions in the country and recently, there has been a major initiative in the growth of private psychiatric services to fill a vacuum that the public mental health services have been slow to address. A number of non-governmental organizations have also initiated activities related to rehabilitation programmes, human rights of mentally ill people, and school mental health programmes. Despite all these efforts and progress, a lot has still to be done towards all aspects of mental health care in India in respect of training, research, and provision of clinical services to promote mental health in all sections of society.     

Factors predicting choice of provider among homeless veterans with mental illness

OBJECTIVE: Homeless persons with serious mental illness are especially likely to lack access to comprehensive medical and psychiatric care. This study examined the relative importance of predisposing factors, illness factors, and enabling factors as determinants of the use of Veterans Affairs (VA) health care services by mentally ill homeless veterans seeking services from a non-VA program. Predisposing factors included demographic characteristics and wartime service; illness factors were related to the type of medical problem and the need to seek medical care; and enabling factors included entitlement to VA medical services and location of VA facilities. METHODS: Logistic regression analysis was used to analyze data for 698 homeless veterans with mental illness who were enrolled in the Access to Community Care and Effective Services and Supports (ACCESS) program. RESULTS: About 56 percent of the mentally ill homeless veterans had used VA services at some time in their lives. Homeless veterans were almost twice as likely as other poor veterans to use VA services; those with a dual diagnosis were also more likely to use VA services. Enabling factors were more important than either predisposing or illness factors in predicting VA service use. Veterans most likely to use VA services were those who received VA benefits that gave them priority access to VA services and those who lived near a VA medical center. CONCLUSIONS: Specific characteristics of the service system and of veterans' entitlement were more important than clinical needs or predisposing factors in predicting service use.     

India mental health country profile

India, the second most populated country of the world with a population of 1.027 billion, is a country of contrasts. It is characterized as one of the world's largest industrial nations, yet most of the negative characteristics of poor and developing countries define India too. The population is predominantly rural, and 36% of people still live below poverty line. There is a continuous migration of rural people into urban slums creating major health and economic problems. India is one of the pioneer countries in health services planning with a focus on primary health care. Improvement in the health status of the population has been one of the major thrust areas for social development programmes in the country. However, only a small percentage of the total annual budget is spent on health. Mental health is part of the general health services, and carries no separate budget. The National Mental Health Programme serves practically as the mental health policy. Recently, there was an eight-fold increase in budget allocation for the National Mental Health Programme for the Tenth Five-Year Plan (2002–2007). India is a multicultural traditional society where people visit religious and traditional healers for general and mental health related problems. However, wherever modern health services are available, people do come forward. India has a number of public policy and judicial enactments, which may impact on mental health. These have tried to address the issues of stigma attached to the mental illnesses and the rights of mentally ill people in society. A large number of epidemiological surveys done in India on mental disorders have demonstrated the prevalence of mental morbidity in rural and urban areas of the country; these rates are comparable to global rates. Although India is well placed as far as trained manpower in general health services is concerned, the mental health trained personnel are quite limited, and these are mostly based in urban areas. Considering this, development of mental health services has been linked with general health services and primary health care. Training opportunities for various kinds of mental health personnel are gradually increasing in various academic institutions in the country and recently, there has been a major initiative in the growth of private psychiatric services to fill a vacuum that the public mental health services have been slow to address. A number of non-governmental organizations have also initiated activities related to rehabilitation programmes, human rights of mentally ill people, and school mental health programmes. Despite all these efforts and progress, a lot has still to be done towards all aspects of mental health care in India in respect of training, research, and provision of clinical services to promote mental health in all sections of society.     

The need for mental health promotion

OBJECTIVE: To examine the concept and evidence for mental health promotion, within an understanding of mental health and mental illness and their determinants. METHOD: A selective review of literature and opinion in the fields of public health and mental health. RESULTS: Mental health and mental illness are often given a low priority, despite growing evidence of the burden of disease and costs to the economy. Improving mental health and reducing mental illness will improve quality of life, public health and productivity. The needs for mental health promotion are complementary to the needs for prevention and treatment of mental illness. The required activities are different. Mental health professionals have a necessary but not sufficient role in mental health promotion. CONCLUSIONS: An understanding that mental illnesses are treatable can encourage early entry to care, improve outcomes and lessen the stigma and discrimination related to mental illness. In primary health care there is some evidence that preventive interventions with groups at high risk of depression can prevent episodes of ill health. However, mental health promotion involves another dimension. Better understanding of the nature of mental health and mental illness is the key to changing the priorities, policies and practices in education, law, social services, housing and health critical in turn to the conditions conducive to mental health.     

Homelessness among persons with serious mental illness in an enhanced community-based mental health system

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.     

Understanding causal paths between mental illness and violence

The stigma associated with mental illness is a major concern for patients, families, and providers of health services. One reason for the stigmatization of the mentally ill is the public perception that they are violent and dangerous. Although, traditionally, mental health advocates have argued against this public belief, a recent body of research evidence suggests that patients who suffer from serious mental conditions are more prone to violent behaviour than persons who are not mentally ill. It is a point of contention, however, whether the relationship between mental illness and violence is only one of association, or one of causality; that mental illness causes violence. A proven causal association between mental illness and violence will have major consequences for the mentally ill and major implications for caregivers, communities, and legislators. This paper outlines the key methodological barriers precluding casual inferences at this time. The authors suggest that a casual inference about mental illness and violence may yet be hasty. Because a premature statement advocating a causal relationship between mental illness and violence could increase stigma and have devastating effects on the mentally ill the authors urge researchers to consider the damage that may be produced as a result of poorly substantiated causal inferences.