Utilization of public mental health services by children with serious emotional disturbances

The Integrated Database (IDB) was created to provide a broad picture of the use of state-funded mental health (MH) and substance abuse (SA) services. Assembled separately for three states (Delaware, Oklahoma, and Washington), the IDB links client-level and service-level data maintained by the state MH, SA, and Medicaid agencies. This study used the IDB to examine public MH services for children with serious emotional disturbances (SED) in 1996. Children with SED represented 9% to 22% of all children with MH service use. Between one half and two thirds of children with SED received psychotropic medication; 20% to 40% had a MH inpatient or residential stay. Medicaid was the primary funder of MH services for children with SED; only 2% to 12% of children with SED received services solely through the state MH agency.     

Service Use and Unmet Needs in Youth Suicide: A Study of Trajectories

Objective:

While 90% of suicide victims have suffered from mental health disorders, less than one-half are in contact with a mental health professional in the year preceding their death. Service use in the last year of life of young suicide victims and control subjects was studied in Quebec. We wanted to determine what kinds of health care services were needed and if they were actually received by suicide victims.

Method:

We recruited 67 consecutive suicide victims and 56 matched living control subjects (aged 25 years and younger). We evaluated subjects’ psychopathological profile and determined which services would have been indicated by conducting a needs assessment. We then compared this with what services were actually received.

Results:

Suicide victims were more likely than living control subjects to have a psychiatric diagnosis. They were most in need of services to address substance use disorder, depression, interpersonal distress, and suicide-related problems. There were significant deficits in the domains of coordination and continuity of care, mental health promotion and training, and governance.

Conclusions:

Our results show that we need to urgently take action to address these identified deficits to prevent further loss of life in our young people.     

Multisystemic Therapy Versus Hospitalization for Crisis Stabilization of Youth: Placement Outcomes 4 Months Postreferral

Hospitalization and out-of-home placement data for 113 youth participating in a randomized trial comparing home-based multisystemic therapy (MST; n = 57) with hospitalization(n = 56) for psychiatric crisis stabilization were analyzed following the completion of MST treatment—approximately 4 months post approval for emergency psychiatric hospitalization. Analyses showed that MST prevented any hospitalization for 57% of the participants in the MST condition and reduced the overall number of days hospitalized by 72%. Importantly, the reduction in use and length of hospitalization was not offset by increased use of other placement options, as MST reduced days in other out-of-home placements by 49%. The cost implications for the viability of MST as an alternative to hospitalization for youth presenting psychiatric emergencies are discussed.     

Inner-City Child Mental Health Service Use: The Real Question Is Why Youth and Families Do Not Use Services

OBJECTIVE: This study examines pathways to urban child mental health care as well as explores reasons why care was not received. METHODS: A single group longitudinal design was used to study initial attendance rates at an outpatient child mental health clinic and identify factors associated with initial service use for urban children and their families. RESULTS: Approximately one-third of families (n = 82) do not follow up with care despite their child being referred and an initial appointment scheduled. Yet, three-quarters of those who did not attend a first session still wanted services when interviewed. Factors most significantly related to service use were social support and parental skill efficacy. Miscommunication between adult caregiver and provider was the most often cited reason for non-attendance. CONCLUSIONS: There is a significant unmet need for care along with identification of significant barriers to access. Empirical findings can serve as the basis for modifying urban child mental health service delivery systems.     

Addressing the needs of youth in transition to adulthood

The appalling young-adult outcomes of youth with serious emotional disturbance who are served in public systems demonstrate a failure of standard services to address the unique needs of these youths during their transition from adolescence to adulthood. This article discusses the needs of this population and the current ability of mental health and other relevant agencies to meet those needs. The contrast between needs and system status is presented through a framework of contrasting developmental and institutional transitions. This article reviews the barriers to effective system reform, and the recommendations for changes made by national panels focused on transition and applied research.     

Impact of Multi-Agency Employment Services on Employment Rates

Adults with severe and persistent mental illness who received employment services through mental health and/or vocational rehabilitation programs had higher employment rates than individuals who did not receive any employment services. Individuals who received services from both programs had significantly higher employment rates than individuals who received services from only one program. Results indicate that employment services had a greater relative effect on older clients and clients with a schizophrenia diagnosis than on other individuals. This state-wide study relied exclusively on analysis of administrative/operational databases that provide the employment rates for both recipients of vocational services and other clients.     

Creating an innovative youth mental health service in the United Kingdom: The Norfolk Youth Service

Young people attempting to access mental health services in the United Kingdom often find traditional models of care outdated, rigid, inaccessible and unappealing. Policy recommendations, research and service user opinion suggest that reform is needed to reflect the changing needs of young people. There is significant motivation in the United Kingdom to transform mental health services for young people, and this paper aims to describe the rationale, development and implementation of a novel youth mental health service in the United Kingdom, the Norfolk Youth Service. The Norfolk Youth Service model is described as a service model case study. The service rationale, national and local drivers, principles, aims, model, research priorities and future directions are reported. The Norfolk Youth Service is an innovative example of mental health transformation in the United Kingdom, comprising a pragmatic, assertive and “youth‐friendly” service for young people aged 14 to 25 that transcends traditional service boundaries. The service was developed in collaboration with young people and partnership agencies and is based on an engaging and inclusive ethos. The service is a social‐recovery oriented, evidence‐based and aims to satisfy recent policy guidance. The redesign and transformation of youth mental health services in the United Kingdom is long overdue. The Norfolk Youth Service represents an example of reform that aims to meet the developmental and transitional needs of young people at the same time as remaining youth‐oriented.     

Inpatient Hospitalizations and Emergency Service Visits Among Participants in an Individual Placement and Support (IPS) Model Program

Supported employment (SE) is considered an "evidence-based" practice for people with serious mental illness. We examined inpatient hospitalizations and emergency service visits among clients in a SE program based on the Individual Placement and Support (IPS) model in comparison to a propensity score matched group of clients who did not participate in IPS. A significant interaction showed that only IPS/SE clients who were also high in regular mental health services had fewer hospitalizations and emergency service visits than matched controls. The interaction effect was moderate, even when we controlled for client functioning. These findings provide support for the integration of mental health and vocational rehabilitation services, a key feature of evidence-based SE services.     

Transportability of Multisystemic Therapy: Evidence for Multilevel Influences

This study examines factors associated with the implementation and short-term outcomes in dissemination sites of Multisystemic Therapy (MST), an intensive, short-term, family- and community-based treatment for serious antisocial behavior in youth. Participants were 666 children and families served by 217 therapists in 39 sites. Pre- (T1) to immediate posttreatment (T2) differences in child problems and functioning were similar in magnitude to those found in randomized trials of MST. Results of random effects regression supported direct effects of therapist adherence, organizational climate, and structure at baseline on immediate posttreatment child outcomes. However, organizational factors were unrelated to adherence; thus, a hypothesized mediation model in which organizational climate and structure affect outcomes through therapist adherence to MST was not supported. Furthermore, the direction of associations between some organizational climate variables and outcomes countered expectations. Post hoc moderation analyses clarify these findings, with organizational effects differing by level of therapist adherence during treatment. Implications for the transfer of evidence-based psychosocial treatments for youth to usual care practice settings are discussed.     

CONNECT: A Measure of Continuity of Care in Mental Health Services

This paper introduces a measure of continuity of care (CONNECT) developed for mental health services research. CONNECT addresses qualities of interpersonal interaction in service-user/practitioner relationships through 13 scales and one single-item indicator. The scales are grouped into five domains: knowledge, flexibility, availability, coordination, and transitions. Domains were derived from ethnographic data. Service users rate responses to items using 5-point scales. The measure is administered in interview format. CONNECT was developed for use with persons who have serious mental illness. Preliminary testing included cognitive interviews and two pilot studies. The results of a field test in which 400 persons with serious mental illness completed CONNECT indicate that the measure is easily administered and produces well-distributed responses. Five scales meet the .80 criterion for internal-consistency reliability for group-level research. Estimates of 2-week test-retest reliability indicate fair- to-good agreement. A broad initial validation strategy including known groups and convergent validity assessments produced results that will inform and focus future efforts. Next steps in the measure development process are discussed.     

Understanding the Landscape of Psychosocial Intervention Practices for Social,Emotional, and Behavioral Challenges in Youth With ASD: A Study Protocol

Introduction: There is a significant gap between research and practice for mental health services for youth with autism spectrum disorder (ASD). Despite increased numbers of individuals with ASD treated in community settings, little is known about the array of practices used with this population and the extent to which providers are aware of and use evidence-based strategies. The goal of this article is to describe a protocol for developing a more comprehensive understanding of the landscape of current intervention practices and attitudes regarding the treatment of psychosocial issues in youth with ASD in community settings within the United States. Methods: This article describes our research protocol for developing a comprehensive survey—the Usual Care for Autism Survey (UCAS)—to capture the depth and breadth of practices for youth with ASD and attitudes of community-based providers. Phase 1 will involve a comprehensive review of published literature to identify intervention practices for social difficulties, anxiety, and externalizing symptoms in youth with ASD (7–22 years). Phase 2 will involve developing and piloting the UCAS using the qualitative approaches and Delphi methodology. In Phase 3, we will distribute the UCAS to approximately 700 providers across the United States to ascertain the frequency of intervention practices being delivered to youth with ASD and provider attitudes toward practices in usual care practice settings. Conclusions: Results will assist the work of researchers, clinicians, and policymakers to support the implementation of effective practices and improve the quality of services for youth with ASD.     

Determinants of Service Placements for Youth with Serious Emotional and Behavioral Disturbances

This paper examines the association between race and type of service placement for youth with serious emotional and behavioral disturbances. Placements were reviewed for 2,803 black and white youth served in the community mental health system. Differences were found between black and white youth in the type of out-of-home placements they received after controlling for sociodemographic variables and presenting problems. Black youth were more likely than whites to be placed in correctional facilities and foster care while white youth were more likely than blacks to be hospitalized (p < .001). This variation in placement may not be clinically warranted. Placement criteria and outcome assessments are needed.     

Urgent Psychiatric Services: A Scoping Review

Objective:

Urgent psychiatric services can provide timely access to ambulatory psychiatric assessment and short-term treatment for patients experiencing a mental health crisis or risk of rapid deterioration requiring hospitalization, yet little is known about how best to organize mental health service delivery for this population. Our scoping review was conducted to identify knowledge gaps and inform program development and quality improvement.

Method:

We searched MEDLINE, PsycINFO, CINAHL, Embase, and EBM Reviews for English-language articles, published from January 1993 to June 2014, using relevant key words and subject headings. Reverse and forward citations were manually searched using reference lists and Google Scholar. Articles were included if they described programs providing ambulatory psychiatric assessment (with or without treatment) within 2 weeks of referral.

Results:

We identified 10 programs providing urgent psychiatric services. Programs targeted a diagnostically heterogeneous population with acute risks and intensive needs. Most programs included a structured process for triage, strategies to improve accessibility and attendance, interprofessional staffing, short-term treatment, and efforts to improve continuity of care. Despite substantial methodological limitations, studies reported improvements in symptom severity, distress, psychosocial functioning, mental health–related quality of life, subjective well-being, and satisfaction with care, as well as decreased wait times for post-emergency department (ED) ambulatory care, and averted ED visits and admissions.

Conclusions:

Urgent psychiatric services may be an important part of the continuum of mental health services. Further work is needed to clarify the role of urgent psychiatric services, develop standards or best practices, and evaluate outcomes using rigorous methodologies.     

Assessing the Strengths of Children Referred for Community-Based Mental Health Services

This study investigated the relationship between child strengths and functional impairment, specifically whether youth with greater levels of functional impairment also exhibit strengths. The relationship was investigated for children (N = 1,838) of different genders, ages, race, and ethnic backgrounds and whose families were living at different income levels. A moderate relationship was found between child strengths and functional impairment. Those children with even the most severe functional impairment were rated as having average or near average strengths. With the exception of gender, the relationship between impairment and strengths did not differ as a function of demographic characteristics. These findings provide additional support for the construct validity of the Behavioral and Emotional Strengths Rating Scale (M. Epstein & J. Sharma, 1998) and they highlight the need for strength-based assessment and screening for youth entering mental health services. Child strengths as the foundation for service planning and implementation, and other implications are discussed.     

Utilization of Public Mental Health Services by Adults with Serious Mental Illness

Public mental health (MH) services were examined for non-elderly adults with serious mental illness (SMI) using a database combining information from Medicaid, MH, and substance abuse agencies in three states. These data show that between 23% and 39% of those with SMI received MH services only through Medicaid. Relative use of community versus state hospitals for delivery of psychiatric inpatient care varied across the three states. However, state hospitals accounted for a large proportion of total inpatient days, due to high mean annual days of care. In two states, Medicaid paid for fewer psychiatric inpatient days than expected.     

Psychiatric Emergency Services: A Review of the Literature and a Proposed Research Agenda

To gain a better understanding of the scope of previous research on psychiatric emergency services (PES) and to identify areas of focus for future studies, the author reviews PES literature published between 1983 and 2003. PES literature was identified by performing a MEDLINE search. The author was interested in studies or reviews of all types of PES. The refereed research, consisting of 85 articles, is a representation of the existing literature as multiple studies were found to be similar in topic and methodology. This review is organized using Donabedians structure, process, outcome framework to describe research that has examined 1) providers, clients, and services; 2) variations in access, utilization, evaluation, treatment, and continuity of care; and 3) outcomes of these services. The resulting report reveals methodological limitations that are pervasive throughout the PES literature, dimensions of psychiatric emergency services that remain unexplored, and a PES research agenda.