Internalizing stigma associated with mental illness: findings from a general population survey in Jamaica.

OBJECTIVES: The culture of stigma associated with mental illness is particularly intense when persons who are normally victims of that stigmatization (mentally ill persons and their family members) themselves act negatively toward others whom they associate with mental illness. We attempt to determine the extent of this internalization and assimilation of stigmatizing attitudes, cognitions, and behaviors in persons who are at risk for such stigmatization in Jamaica. METHODS: Data from a 2006 national survey on mental health were analyzed. Demographic variables, the presence or absence of mental illness in respondents and in their family members, and responses pertaining to behaviors and attitudes toward mentally ill persons were examined. Subsamples (respondents with mental illness, respondents with a family member with mental illness, respondents with neither) were compared using the chi-square test. RESULTS: Respondents with family members with mental illness were less likely to demonstrate a number of different manifestations of stigmatization than others (P=0.009-0.019). Respondents with mental illness showed no difference in the demonstration of a number of different manifestations of stigmatization from other respondents (P=0.069-0.515). CONCLUSIONS: The small number of mentally ill respondents resulted in low statistical power for demonstrating differences between that subgroup and other respondents. The significantly more positive attitudes and behavior of respondents with family members with mental illness suggest that some benefit may be gained by creating more opportunities for the general public to interact with persons with mental illness.     

Estimating the employment and earnings costs of mental illness: recent developments in the United States

Substantial attention has recently been focused on both the prevalence and consequences of mental illness. Generally, public interest in the costs of mental illness has been limited to the direct costs of treating the mentally ill. In this paper, we consider the magnitude and importance of a major component of the indirect costs of mental illness: employment and earnings losses. We first describe the technical difficulties involved in estimating these costs. We then describe new data and recent advances in the United States that have improved our ability to make such estimates. Our conclusions from the recent research are that each year in the United States 5-6 million workers between the ages of 16 and 54 lose, fail to seek, or cannot find employment as a consequence of mental illness. Among those who do work, we estimate that mental illness decreases annual income by an amount between $3,500 and $6,000. We then discuss an emerging challenge to the traditional method for arriving at such estimates: the friction cost approach. We describe both the conceptual and technical differences between the friction cost method and the traditional human capital approach. We conclude that while economic context has much to do with whether one relies on human capital or friction cost estimates, each can offer useful information about labor market losses due to mental illness.     

Responding to the needs of the homeless mentally ill

The homeless mentally ill represent a pivotal and urgent challenge to the mental health field in the 1980s. Those homeless who have extended histories of psychiatric hospitalization stand as harsh reminders of the failures of deinstitutionalization, while young mentally ill homeless adults who never have been treated as inpatients testify to the gaps and unrealized promises of community-based care under deinstitutionalization. Homelessness and mental illness are social and clinical problems, respectively, distinct in some ways but intertwined in others. Some of the factors that contribute to homelessness--such as economic deprivations, a dearth of low-cost housing, discontinuities in social service systems, and radical changes in the composition of American families--are felt particularly keenly by many persons who are mentally ill. And symptoms of mental disorders, in turn, frequently impede an individual's capacities to cope with those, as well as other, stressors. Developing appropriate and effective responses to the needs of homeless people who are mentally ill requires precise definition and identification of the target population, innovations in the mental health service system, encouragement of those who staff it to work with homeless mentally ill patients, and public education. Ultimately, however, fundamental answers will be found in an improved understanding of severe mental illness, enhanced treatment capacities, and greater attention to the rehabilitative needs of mentally ill persons.     

Self-reported lifetime psychiatric hospitalization histories of jail detainees with mental disorders: comparison with a non-incarcerated national sample

Lack of access to hospitalization is an often-cited risk factor for incarceration among persons with severe mental illness. This proposition is examined by comparing self-reports of lifetime psychiatric hospitalization histories of mentally ill jail inmates with data from a national sample of non-incarcerated mentally ill. Roughly 52% of mentally ill jail detainees reported at least one psychiatric hospitalization, a rate nearly three times that of the comparison group. The data call into question the notion that mentally ill jail inmates have reduced access to psychiatric inpatient treatment, without addressing the adequacy of the treatment received. Longitudinal studies are needed to explore temporal relationships to better understand the relationship between mental health treatment and criminal justice involvement.     

The labor market consequences of family illness

BACKGROUND: This study examines the impact of mental illness on the labor market performance of family members of afflicted individuals. Numerous research projects have attempted to measure the impact of mental illness and related disorders on the ill individual, yet have traditionally neglected estimating potential costs accruing to family members of the ill. AIMS OF THE STUDY: Previous research estimating the impact of illness on the time allocation decisions of family caregivers has been limited in scope. I obtain estimates of the impact of mental illness on the probability of labor force participation and hours of work of all family members. The general analysis used in this study will pave the way for more accurate assessments of the costs of all types of illness and the estimates obtained will provide policy makers with a much more complete picture of the costs of mental illness. METHODS: The main empirical work in this study includes a probit estimation of labor force participation and a tobit regression of hours worked (including sample selection correction). The data sample, taken from the 1987 National Medical Expenditure Survey, is also partitioned by gender to clarify effects of family illness on labor supply for both females and males. RESULTS: Adult males are found to increase their probability of labor force participation in the presence of mental illness in the family (all else equal) when the mental illness is accompanied by a chronic physical illness. However, females are surprisingly found to have no significant impact on their probability of being a member of the labor market when a family member is afflicted with mental illness. On the other hand, hours of work are significantly reduced for both females and males when the mentally ill family member is afflicted with additional illnesses (physical and/or mental). DISCUSSION: Previous studies have traditionally not considered the effects of family illness on males because females are typically found to be the primary caregiver when a family member falls ill. The findings in this study indicate that men suffer reductions in their hours of work in an equivalent magnitude to females. Thus, males should not be ignored when estimating the opportunity costs of illness in families. IMPLICATIONS FOR HEALTH POLICIES: Current federal and state policies provide for some of the medical costs and replace some of the lost income of ill individuals, but generally do not support family members who are negatively affected by illness. This research provides evidence supporting the arguments of advocates for policy to ameliorate the financial burden borne by family members of the ill. IMPLICATIONS FOR FUTURE RESEARCH: The estimates obtained in this study show that women and men both need to be studied when determining the effects of family illness on labor supply, and should be studied separately to obtain clear results. Also, future research should include examining particular mental illnesses to see whether there is a higher cost of one over the other (e.g., schizophrenia versus major depression), as this may provide valuable information to policy makers. In addition, comparison of the costs of psychological disorders to chronic physical illnesses (such as cancer and heart disease) should be undertaken.     

Parenting and the significance of children for women with a serious mental illness

Increased time in the community has made developmental life tasks of adulthood more relevant to individuals with severe mental illness (SMI). Parenting and motherhood are thus important areas of study, since it has been established that women with SMI are likely to have children. Previous research has concentrated primarily on the deleterious effects on the child of having a mentally ill parent. Mothers' capabilities or problems in parenting and the meaning of motherhood from the women's perspective have received limited attention. In the present interview study of 24 mothers with mental illness, satisfaction and self-reported competency in parenting were found to be high, although significant economic and some support problems were reported. Women described the meaning of children and the significance of the parenting role, yet realistically portrayed their concerns over discipline and the effects their problems have. Implications for mental health services are discussed.     

Inequality in the social consequences of illness: how well do people with long-term illness fare in the British and Swedish labor markets?

The demand for unskilled labor has collapsed across industrialized societies, including Britain and Sweden, and rates of unemployment and economic inactivity have increased. The result is a reduction in total employment, primarily among men. These trends could be expected to hit particularly hard those people with chronic illness. The study tests two opposing hypotheses: (1) the increasingly flexible, deregulated labor market in Britain would result in an increased number of new jobs, and thus better employment opportunities for unskilled workers, including those with chronic illness; (2) the more regulated labor market in Sweden, with the associated health and social policies, would provide greater opportunities for jobs and job security for workers with chronic illness. Analysis of data on men from the British General Household Survey and the Swedish Survey of Living Conditions, 1979-1995, showed that employment rates were higher and rates of unemployment and economic inactivity were lower in Sweden than in Britain, and the differences in these rates across socioeconomic groups and between those with and without chronic illness were smaller in Sweden. The results support the hypothesis that active labor market policies and employment protection may increase the opportunities for people with chronic illness to remain in work.     

Mental illness and length of inpatient stay for medicaid recipients with AIDS

OBJECTIVE: To examine the associations between comorbid mental illness and length of hospital stays (LOS) among Medicaid beneficiaries with AIDS. DATA SOURCE AND COLLECTION/STUDY SETTING: Merged 1992-1998 Medicaid claims and AIDS surveillance data obtained from the State of New Jersey for adults with >or=1 inpatient stay after an AIDS diagnosis from 1992 to 1996. STUDY DESIGN: Observational study of 6,247 AIDS patients with 24,975 inpatient visits. Severe mental illness (SMI) and other less severe mental illness (OMI) diagnoses at visits were ascertained from ICD-9 Codes. About 4 percent of visits had an SMI diagnosis; 5 percent had an OMI diagnosis; 43 percent did not have a mental illness diagnosis, but were patients who had been identified as having an SMI or OMI history; and 48 percent were from patients with no identified history of mental illness. PRINCIPAL FINDINGS: The overall mean hospital LOS was 12.7 days. After adjusting for measures of HIV disease severity and health care access in multivariate models, patients presenting with primary and secondary severe mental illness (SMI) diagnoses had approximately 32 percent and approximately 11 percent longer LOS, respectively, than did similar patients without a mental illness history (p<0.001 for each). But in these adjusted models of length of stay: (1) diagnosis of OMI was not related to LOS, and (2) in the absence of a mental illness diagnosed at the visit, an identified history of either SMI or OMI was also not related to LOS. In adjusted models of time to readmission for a new visit, current diagnosis of SMI or OMI and in the absences of a current diagnosis, history of SMI or OMI all tended to be associated with quicker readmission. CONCLUSIONS: This study finds greater (adjusted) LOS for AIDS patients diagnosed with severe mental illness (but not for those diagnosed with less severe mental comorbidity) at a visit. The effect of acute severe mental illness on hospitalization time may be comparable to that of an acute AIDS opportunistic illness. While previous research raises concerns that mental illness increases LOS by interfering with treatment of HIV conditions, the associations here may simply indicate that extra time is needed to treat severe mental illnesses or arrange for discharge of afflicted patients.     

Obstetric Complications in Women with Diagnosed Mental Illness: The Relative Success of California's County Mental Health System

Objective. To examine disparities in serious obstetric complications and quality of obstetric care during labor and delivery for women with and without mental illness.
Data Source. Linked California hospital discharge (2000–2001), birth, fetal death, and county mental health system (CMHS) records.
Study Design. This population-based, cross-sectional study of 915,568 deliveries in California, calculated adjusted odds ratios (AORs) for obstetric complication rates for women with a mental illness diagnosis (treated and not treated in the CMHS) compared with women with no mental illness diagnosis, controlling for sociodemographic, delivery hospital type, and clinical factors.
Results. Compared with deliveries in the general non–mentally ill population, deliveries to women with mental illness stand a higher adjusted risk of obstetric complication: AOR=1.32 (95 percent confidence interval [CI]=1.25, 1.39) for women treated in the CMHS and AOR=1.72 (95 percent CI=1.66, 1.79) for women not treated in the CMHS. Mentally ill women treated in the CMHS are at lower risk than non-CMHS mentally ill women of experiencing conditions associated with suboptimal intrapartum care (postpartum hemorrhage, major puerperal infections) and inadequate prenatal care (acute pyelonephritis).
Conclusion. Since mental disorders during pregnancy adversely affect mothers and their infants, care of the mentally ill pregnant woman by mental health and primary care providers warrants special attention.     

Effect of job loss due to plant closure on mortality and hospitalization

We investigate whether job loss due to plant closure causes an increased risk of (cause-specific) mortality and hospitalization for male workers having strong labour market attachment. We use administrative data: a panel of all persons in Denmark in the period 1980-2006, containing records on health and work status, and a link from workers to plants. We use propensity score weighting combined with non-parametric duration analysis. We find that job loss increases the risk of overall mortality and mortality caused by circulatory disease; of suicide and suicide attempts; and of death and hospitalization due to traffic accidents, alcohol-related disease, and mental illness.     

Mental health costs and access under alternative capitation systems in Colorado

OBJECTIVE: To examine service cost and access for persons with severe mental illness under Medicaid mental health capitation payment in Colorado. Capitation contracts were made with two organizational models: community mental health centers (CMHCs) that manage and deliver services (direct capitation [DC]) and joint ventures between CMHCs and a for-profit managed care firm (managed behavioral health organization, [MBHO]) and compared to fee for service (F.F.S.). DATA SOURCES/STUDY SETTING: Both primary and secondary data were collected for the year prior to the new financing policy and the following two years (1995-1998). STUDY DESIGN: A stratified random sample of 522 severely mentally ill subjects was selected from comparable geographic areas within the capitated and FFS regions of Colorado. Major variables include service cost, utilization, and access (probability of service use) derived from secondary claims data, subject reported access collected at six-month intervals, and baseline outcomes (symptoms, functioning, and quality of life). PRINCIPAL FINDINGS: In comparison to the FFS area, cost per person was reduced in the capitated areas in each of the two years following implementation. By the end of year two, cost per person was reduced by two-thirds in the MBHO areas and by one-fifth in the DC areas. Reductions in access were found for both capitated areas, although reductions in utilization for those receiving service were found only in the MBHO model. CONCLUSIONS: Medicaid mental health capitation in Colorado resulted in cost reducing service changes for persons with severe mental illness. Assessment of outcome change is necessary to identify cost effectiveness.     

Predictors and course of vocational status, income, and quality of life in people with severe mental illness: a naturalistic study

Due to high unemployment rates, people with mental illness are at risk of poverty and are deprived of the social and psychological functions of work, such as the provision of social support, structuring of time, and self-esteem, with a negative effect on their perceived quality of life (QoL). Two distinct processes are held responsible for the low work force participation of people with mental illness: 'Social underachievement' and 'social decline'. Social underachievement signifies that, due to early illness onset, the educational attainment of people with mental illness is low and entry to the labor market fails. Social decline, on the other hand, describes the loss of competitive employment after illness onset, followed by prolonged periods of unemployment and difficulties to re-enter the labor market. This study examines how social underachievement and decline are reflected in the course of vocational status, income, and QoL of people with severe mental illness in the years after a psychiatric admission in a naturalistic longitudinal design. A total of 176 participants diagnosed with schizophrenia or affective disorders were interviewed during an index hospitalization in two large psychiatric hospitals in Zurich. Follow-up interviews were conducted 12 and 30 months after. Random coefficient models (multilevel models) were used to examine simultaneously the predictors and course of the variables of interest. A low number of psychiatric hospitalizations, a higher educational degree, a diagnosis of schizophrenia, and years of work experience predicted a higher vocational status. Vocational status decreased in first-admission participants with prolonged hospitalizations during the follow-up period. Income did not change over time and was positively influenced by a higher age of illness onset, competitive employment, higher education, and not having had a longer hospitalization recently. Subjective QoL significantly improved and was rated higher by people with any kind of employment than by participants without a job. Participants with an affective disorder, those with few hospitalizations but a recent inpatient stay of longer duration, showed lower QoL. Including employment issues early in treatment is especially important for people with an early illness onset and those with more severe forms of psychiatric disorder. A life course perspective enhances the understanding of patients' vocational potential and needs for support.     

'There but for the grace of God': moral responsibility and mental illness

Abstract Setting the terms of praise‐ and blameworthiness has long dominated philosophers’ discussions of responsibility. Analytic philosophy has most often looked to reason and the abstract relations between individual rational judgements and actions to advance the discourse on moral responsibility. Those whose capacity for reasoned judgement is impaired are deeply problematic. Is it proper to morally appraise ‘the mentally ill’? The philosopher T.M. Scanlon discusses moral responsibility as a precondition of moral appraisal and contends that it is not appropriate to appraise a person as (morally) praise‐ or blameworthy if that person cannot be held responsible for the action(s) for which he is being praised or blamed. What are the conditions, then, under which one can properly be said to be responsible for one's actions? Can one hold ‘the mentally ill’ responsible for their actions? If not, can it in any way be reasonable to expect them to ‘take responsibility’ for their actions and/or characters? The expectation that ‘the mentally ill’ will attempt to control, i.e. take responsibility for their behaviour despite the fact of their mental illness is a pervasive feature of psychiatric approaches to the care and treatment of ‘the mentally ill’. It would seem that such treatment approaches are coherent only to the degree ‘the mentally ill’ can be considered responsible moral agents. This paper explores these issues with regard to that form of mental illness categorized as the personality disorders. It describes the morally and clinically relevant features of personality disorder, explains how they do not fit traditional analytic paradigms of ‘mental illness’ and elaborates the argument that persons with this category of mental illness are fully moral persons who are rightly subject to praise and blame.     

Civil commitment of sex offenders to mental institutions: should the standard be based on serious mental illness or mental disorder?

Civil commitment to mental institutions requires that an individual be both seriously mentally ill and dangerous. This principle is erroneously being applied to incarcerated sex offenders nearing release from prison under the theory that they have antisocial personalities or paraphilia disorders, which are called mental illnesses. However, the mental health and legal communities are at odds regarding the use of a diagnosis of personality disorder or paraphilia to justify civil commitment. The author reviews the differences between serious mental illness and mental disorder, the flaws with assessing sex offenders as mentally ill, and the ethical dilemma for social workers employed in mental hospitals.     

State level classification of serious mental illness: a case for a more uniform standard

This study reports a national survey of U.S. states that was conducted from July of 1999 through March of 2001. The lack of consistent data on serious mental illness (SMI) provided the impetus for this study. Data was collected through a survey on states' definitions of SMI, on demographic information for patients with SMI, and on total annual per capita expenditures for SMI. Based on a 100% response rate, we found considerable variation among states in the definition used for SMI and the records kept on patients with SMI. This paper also involves a state-level statistical analysis of factors that may influence rates of per capita expenditures for SMI. The main finding using regression analysis was that per capita income and state definitions of mental illness that included DSM-III, DSM-IV, and ICD-9-CM diagnoses are significant and positively associated with a state's per capita expenditures for SMI. An additional finding is that accounting for all of the above factors, there still remains significant differences across major census divisions in per capita expenditures for the seriously mentally ill. Another major finding is that more consistent data collection is needed to take an epidemiological approach toward understanding the social conditions that contribute to SMI.     

Prevalence and patterns of major depressive disorder in the United States labor force

BACKGROUND AND AIMS OF THE STUDY: In this paper, we identify the 12-month and lifetime prevalence of major depressive disorder in and out of the labor force, and among the employed and unemployed. We examine whether prevalence by labor force and employment status varies by gender and over the life cycle. Finally, we examine whether people can "recover" from depression with time by identifying patterns of labor force participation and employment as time since most recent episode passes. METHODS: We examine data collected as part of the National Comorbidity Survey, a survey representative of the population of the United States designed to identify the prevalence of major mental illnesses. The National Comorbidity Study identified cases of major depression via the Composite International Diagnostic Interview. Using these data, we estimate univariate and bivariate frequency distributions of major depressive disorder. We also estimate a set of multivariate models to identify the effect of a variety of dimensions of major depression on the propensity to participate in the labor force, and be employed if participating. RESULTS: Lifetime and 12-month prevalence rates of depression are similar in and out of the labor force. Within the labor force, however, depression is strongly associated with unemployment. The negative relationship between depressive disorder and employment is particularly strong for middle age workers. Depression and the number of depressive episodes have a differing pattern of effects on labor market outcomes for men and women. We find evidence that labor force participation and employment rates for people with a history of depression increase significantly over time in the absence of additional depressive episodes. DISCUSSION: Labor market status represents an important dimension along which prevalence of major depression varies. The relationship between depression and employment status is particularly strong for middle aged persons, but becomes weaker as time passes since the last depressive episode. Continued exploration of the association between work (or lack of work) and depression may ultimately help in the prediction, treatment and assessment of the illness. IMPLICASIONS FOR PRACTICE AND POLICY: These results present a basic set of facts about the relationship between major depressive disorder and labor market outcomes. We have not, however, attempted to sort out the complexities of this relationship here. These complexities arise at almost every turn. For instance, the high level of prevalence of depression among the unemployed may be due to the possibility that the stresses associated with unemployment trigger depressive episodes or to the possibility that workers who are depressed are more likely to be fired or quit. IMPLICATIONS FOR FURTHER RESEARCH: Our continuing research attempts to address these problems. Understanding when and how depression affects labor market outcomes and when and how labor market outcomes affect depression is an important endeavor for those interested in treating the disease and understanding its consequences.     

Operating a member-employing therapeutic business as part of an alternative mental health center

The promises of deinstitutionalization have not been kept for unemployed chronically mentally ill people. This article describes an innovative community support program--a nonprofit therapeutic member-run business. Rainbow Services provides opportunities for adults with chronic mental health problems to learn marketable job skills and necessary social skills through participation in various work settings. On-site job training, vocational education, socialization, and job counseling are offered. Thirteen years of business success demonstrate that chronically mentally ill people can function productively in the community. The features of the business are related to beliefs and values familiar to early settlement house workers and social activists and support social work's claim to leadership in working with this population.     

Recasting research into children's experiences of parental mental illness: beyond risk and resilience

Children who live with a mentally ill parent are viewed primarily as being 'at risk' of developing a mental illness themselves and those who remain well are considered extraordinarily resilient. This particular risk/resilience discourse is embedded within larger contemporary discourses about risk and childhood. Childhood is seen as a critical period of development during which children need protection due to their physical and psychological vulnerabilities. In this paper, the implications of this dominant casting of children are explored and it is argued that the conceptual repertoire about those living with a mentally ill parent should be expanded. A critique of the literature that established the risk/resilience discourse is followed by a discussion of research about parenting with a mental illness within which children are surprisingly absent. Recent thinking about children arising out of the 'new' social studies of childhood is summarized to illustrate its resistance to the hegemonic image of children as passive, developing, 'unfinished' persons. A recasting of children as complex young persons who have competencies as well as vulnerabilities linked to their developmental stages, would lead to different lines of inquiry about children's experiences of mental illness in a parent.     

Mental health, duration of unemployment, and coping strategy: a cross-sectional study of unemployed migrant workers in eastern china during the economic crisis

ABSTRACT: BACKGROUND: 20 million migrant workers in China lost their jobs during the economic crisis of 2008. Both urban migration and unemployment have long been documented to be associated with vulnerability to mental problems. This study aims to examine the mental health of unemployed migrant workers in Eastern China and its relation to duration of unemployment and coping strategy during the recent economic crisis. METHODS: The data were collected through interview-based survey with a sample of 210 unemployed migrant workers in Zhejiang Province of China from 2008 to 2009. Symptom Checklist-90-Revised, Coping Strategies Questionnaire, and seven short demographic questions were used. RESULTS: The majority of the unemployed migrant workers were found to be young male manufacturing industry workers with short-term unemployment and a relatively low education level. Nearly 50% of unemployed migrant workers were classified as mentally unhealthy and the most frequently reported symptom was depression. Compared with the adult norm of 1986, 2003, and 2007 in China, unemployed migrants had more mental problems. Long-term unemployed migrant workers had more psychiatric symptoms than the short-term unemployed workers and employed migrant workers. Unemployed migrant workers with immature coping strategies expressed significantly more psychiatric symptoms than those with mixed and mature coping strategies. Duration of unemployment and two coping strategies, problem-solving and self-blaming, predicted the mental problems of unemployed migrant workers. CONCLUSIONS: The results indicated that mental health status of unemployed migrant workers in Eastern China was poorer than the national adult norm. More psychiatric symptoms are evidenced among unemployed migrant workers who lost their jobs for a long term and who had immature coping strategies. These findings can be used for prevention and intervention of mental illness among unemployed migrant workers.     

Identifying the minimal important difference in patient-reported outcome measures in the field of people with severe mental illness: a pre–post-analysis of the Illness Management and Recovery Programme

Quality of Life Research - Complementary interventions for persons with severe mental illness (SMI) focus on both personal recovery and illness self-management. This paper aimed to identify the...