Use of mental health services among older youths in foster care

OBJECTIVE: This study examined lifetime, 12-month, and current mental health service use among older youths in the foster care system and examined variations in mental health care by race, gender, maltreatment history, living situation, and geographic region. METHOD: The Service Assessment for Children and Adolescents, the Child Trauma Questionnaire, and the Diagnostic Interview Schedule were used in interviews with 406 youths in Missouri's foster care system who were aged 17 years. RESULTS: Ninety-four percent of the youths had used a mental health service in their lifetime, 83 percent used a mental health service in the past year, and 66 percent were currently receiving a mental health service. Lifetime rates for inpatient psychiatric care (42 percent) and other residential programs (77 percent) were exceptionally high. A quarter of the youths received mental health services before they entered the foster care system. Among youths who received residential services, half did not receive community-based services before receiving residential services. After the analyses controlled for need, predisposing characteristics, and enabling characteristics, youths of color were less likely to receive outpatient therapy, psychotherapeutic medications, and inpatient services, and they were more likely to receive residential services. Youths who had been neglected and youths in kinship care were less likely to receive some types of services. Geographic differences in service use were common and sometimes mediated the effect of race on service use. CONCLUSIONS: The child welfare system was actively engaged in arranging mental health services for youths in the foster care system, but the system was unable to maintain many youths in less restrictive living situations. The variations by race and geography indirectly indicate quality concerns.     

Service Referral for Juvenile Justice Youths: Associations with Psychiatric Disorder and Recidivism

Secondary multiple regression analyses related disorder profile, probation officers’ mental health/substance use service referrals, and recidivism in 361 juvenile justice youths. Those with externalizing (disruptive behavior or substance use) disorder or substance offenses were most likely to receive service referrals. Substance disordered youths with service referrals had lower recidivism risk compared to counterparts without referrals; referral lowered the recidivism odds to approximately that for youths without a substance use disorder. Providing juvenile justice youths with systematic mental health assessment and linking those with substance use disorder to mental health and substance use services likely reduces recidivism risk.     

Compliance with Mental Health and Other Specialty Care Referrals among Medicare/Medicaid Dual Enrollees

Objectives: To examine and compare non-compliance with mental health and other specialty referrals among low-income elderly.Methods: A survey of 2,128 community-dwelling elderly assessed mental health and other specialty referral in the past year and compliance with these referrals. Non-compliant participants and those who had encountered difficulties in arranging referral appointments were asked about the barriers.Results: 16.7% with mental health referrals vs. 4.8% with other specialty referrals did not comply (p < .001). The main reason for non-compliance with mental health referrals was lack of perceived need.Discussion: Lack of perceived need for professional help is a major barrier to specialty mental health care.     

Mental Health Referrals Reduce Recidivism in First-Time Juvenile Offenders,But How Do We Determine Who is Referred?

While psychiatric disorders are common among juvenile delinquents, many mental health problems go undetected, increasing the likelihood for persistent difficulties. This is the first known study to examine mental health referral rates and recidivism in the juvenile justice system. In addition to the study, we review juvenile justice mental health screening to improve detection and treatment. Juvenile criminal records in conjunction with behavioral health screenings were analyzed to determine differences in referrals and recidivism among first time offenders. Recidivism rates were significantly lower (p = 0.04) and time to recidivism was significantly longer (p = 0.03) for those referred specifically for mental health services than for those without any referrals, even after adjusting for offense severity. While black youths had a significantly higher recidivism rate (p = 0.02) and a shorter time to recidivism (p = 0.009) than white youths, there was no significant difference between races when referred specifically for mental health services. Among the groups studied, black youths had the most profound positive effect from mental health referrals (p < 0.0001). This study indicates the importance of detecting mental health problems among juvenile delinquents, especially for black offenders. The apparent protective effect of mental health interventions necessitates screening that better identifies underlying psychosocial factors rather than strict reliance upon diagnostic criteria and self-report. Broader or even universal mental health referrals for juvenile offenders could reduce future legal system involvement and costs to society. We review potential reasons that mental health problems go undetected and provide recommendations.     

Experiences of pathways to mental health services for young people and their carers: a qualitative meta-synthesis review

Worldwide, growing concern with young people’s mental health is spurring service reform efforts. Such reform requires a full understanding of the experiences of young people and their carers when seeking mental health help. To generate such an understanding, we conducted a meta-synthesis of qualitative literature on the perspectives of youths and their carers on navigating mental health systems. Five electronic databases were searched (Medline, PsycINFO, EMBASE, CINAHL, HealthSTAR). Studies were included if they explored the experiences of pathways to mental health services of persons aged 11–30 years and/or their carers; were published in English or French; and used qualitative methodology. Quality appraisal was conducted using the CASP tool. The synthesis of 31 included studies yielded three themes—initiating contact with mental health services; characteristics of services’ response; and youths’ and carers’ appraisal of services. Themes about initiating contact included mental health literacy, structural barriers, and social support. Service response-related themes included complex pathways, waitlists, eligibility, and fragmented care. In terms of service appraisal, positive encounters featured providers who were accessible and perceived as caring. Negative appraisals resulted from feeling misunderstood and excluded and being ill-informed about treatment. Across diagnoses and settings, youths and carers had difficult experiences accessing mental healthcare. While individual, social, and healthcare factors shaping pathways to care varied, systemic complexities were a common inhibitor. This synthesis informs recommendations for improving mental health services and youths’ pathways to them. It underlines the need for grounding reform in youths’ and carers’ perspectives and needs.

     

Perceived stigma and mental health care seeking

OBJECTIVE: There is limited empirical evidence on the extent to which perceived public stigma prevents individuals from using mental health services, despite substantial recent policy interest in this issue. This study investigated associations between perceived public stigma and mental health care seeking. METHODS: This study used cross-sectional survey data from a representative sample of undergraduate and graduate students (N=2,782) at one university. A five-item scale was used to assess perceived public stigma toward mental health service use. Perceived need for help in the past 12 months and current presence of depressive and anxiety disorders were also assessed. RESULTS: Perceived stigma was higher among males, older students, Asian and Pacific Islanders, international students, students with lower socioeconomic status backgrounds, and students with current mental health problems. Perceived stigma was also higher among those without any family members or friends who had used mental health services and among those who believed that therapy or medication is not very helpful. Perceived stigma was negatively associated with the likelihood of perceiving a need for mental health services, but only among younger students. Among those with probable depressive or anxiety disorders, there was no evidence that perceived stigma was associated with service use. CONCLUSIONS: These results suggest that, at least in this population, perceived stigma may not be as important a barrier to mental health care as the mental health policy discourse currently assumes.     

Mental health services for Latino adolescents with psychiatric disorders

OBJECTIVES: The major objectives of this study were to examine the prevalence of mental disorders and the use of mental health services among Latino adolescents who were receiving services in at least one of five public sectors of care in San Diego County. METHODS: Survey data were gathered for a random sample of adolescents aged 12 to 18 years (N=1,164) who were receiving public-sector care. Mental disorders were assessed with the Diagnostic Interview Schedule for Children, and use of mental health services was assessed with the Service Assessment for Children and Adolescents. RESULTS: Rates of disruptive disorders were significantly lower among Latino adolescents than among white adolescents. Although more than half of the Latino sample received specialty mental health services, those with psychiatric disorders were significantly underserved compared with their white counterparts. Latino adolescents with psychiatric disorders entered specialty mental health services at a later age and had made significantly fewer specialty mental health service visits in the previous year. In multivariate analyses, Latino youths were significantly less likely than white youths to use specialty mental health services independent of diagnosis, gender, age, and the service sector from which they were selected. CONCLUSIONS: Public service systems need to ensure that Latino youths are appropriately assessed for disruptive disorders and that they are provided with appropriate specialty mental health care.     

Service Use by At-Risk Youths After School-Based Suicide Screening

ObjectiveWe sought to examine follow-up service use by students identified at risk for suicidal behavior in a school-based screening program and assess barriers to seeking services as perceived by youths and parents.MethodWe conducted a longitudinal study of 317 at-risk youths identified by a school-based suicide screening in six high schools in New York State. The at-risk teenagers and their parents were interviewed approximately 2 years after the initial screen to assess service use during the intervening period and identify barriers that may have interfered with seeking treatment.ResultsAt the time of the screening, 72% of the at-risk students were not receiving any type of mental health service. Of these students, 51% were deemed in need of services and subsequently referred by us to a mental health professional. Nearly 70% followed through with the screening's referral recommendations. The youths and their parents reported perceptions about mental health problems, specifically relating to the need for treatment, as the primary reasons for not seeking service.ConclusionsScreening seems to be effective in enhancing the likelihood that students at risk for suicidal behavior will get into treatment. Well-developed and systematic planning is needed to ensure that screening and referral services are coordinated so as to facilitate access for youths into timely treatment.     

Use of Mental Health Services by Youths in Public Sectors of Care

The present paper examined the lifetime rates of mental health service use in a representative sample of youths identified as receiving services in at least one sector of care in a publicly funded service system of a large, metropolitan area. Service use was examined in relation to age, gender, mental health diagnostic status, and service sector involvement. Participants were 1706 youths ages 6-17 years who were active in at least one of the following service sectors: alcohol and drug services, child welfare, juvenile justice, mental health, and special education services for serious emotional disturbance. Structured service use and diagnostic interviews were administered to youths and their caregivers. High lifetime rates of mental health service use were found. Eighty-seven percent of the sample used at least one outpatient service, 45% used at least one inpatient service, and 71% reported use of a school-based service. Youths involved with the mental health and special education sectors had the highest rates of service use. In contrast, youths enumerated from the juvenile justice system tended to have the lowest rates of use. Additional research is needed to refine our understanding of the factors associated with the observed patterns of service use.     

Experiences of and attitudes toward mental health services among older youths in foster care

OBJECTIVES: This study explored the experiences of youths in the Missouri foster care system who were receiving mental health services in order to identify characteristics that they valued in relationships with mental health professionals and in the services they received and to examine whether their attitudes toward services were associated with their experiences with services. METHODS: As part of a larger study, 389 youths aged 17 years were asked open-ended questions about their experiences with mental health providers. The qualitative responses were classified through thematic analysis, and the frequencies of themes were assessed. Service use was measured, and the confidence subscale of the Attitude Toward Seeking Professional Psychological Help scale was used to measure attitudes. RESULTS: Youths' comments generally centered on three aspects of their mental health care: their relationship with their mental health provider, the level of professionalism of their provider, and the effects of the treatment, including medication management. Youths who reported only negative experiences had less positive attitudes toward services than other youths, but they were not any more likely to have experienced changes in service use or medication six months later. CONCLUSIONS: Soliciting feedback from youths about mental health services is important to the provision of high-quality care. In addition to themes identified in similar studies, this study suggests that medication management plays an important role in the acceptability of the treatment that youths receive.     

Utilization of alcohol, drug, and mental health treatment services among American Indian adolescent detainees.

OBJECTIVE: To describe the relationship between psychiatric status and the use of alcohol, drug, and mental health (ADM) services among a sample of American Indian (AI) juvenile detainees. METHOD: A structured diagnostic and service use interview was administered to 150 AI youths detained in a juvenile detention center located on a Northern Plains reservation. RESULTS: Forty percent of AI youths with a diagnosed substance use disorder and 34.1% with a diagnosed anxiety, mood, or disruptive behavior disorder reported lifetime use of services for substance use and emotional problems, respectively. While services for substance use problems were most commonly provided in residential settings, services for emotional problems were most commonly provided in outpatient settings. Traditional healers and pastoral counselors provided services to 23.7% and 29.6% of youths who received services for substance use and emotional problems, respectively. Detained youths were more likely to receive ADM services than AI adolescents living at--large in another, comparable Northern Plains reservation community. Still, the vast majority of youths in detention who suffered from psychiatric disorders did not report use of ADM services. CONCLUSIONS: Detention facilities serving AI adolescents need to screen carefully for the presence of psychiatric disorders and facilitate the use of ADM services.     

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

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

Pathways into and through mental health services for children and adolescents

OBJECTIVE: This study examined points of entry into the mental health service system for children and adolescents as well as patterns of movement through five service sectors: specialty mental health services, education, general medicine, juvenile justice, and child welfare. METHODS: The data were from the Great Smoky Mountains Study, a longitudinal epidemiologic study of mental health problems and service use among youths. The sample consisted of 1,420 youths who were nine, 11, or 13 years old at study entry. Each youth and a parent were interviewed at baseline and every year thereafter about the use of services for mental health problems over the three-year study period. RESULTS: Population estimates indicated that 54 percent of youths have used mental health services at some time during their lives. The education sector was the most common point of entry and provider of services across all age groups. The specialty mental health sector was the second most common point of entry for youths up to age 13 years, and juvenile justice was the second most common point of entry for youths between the ages of 14 and 16. Youths who entered the mental health system through the specialty mental health sector were the most likely to subsequently receive services from other sectors, and those who entered through the education sector were the least likely to do so. CONCLUSIONS: The education sector plays a central role as a point of entry into the mental health system. Interagency collaboration among three primary sectors-education, specialty mental health services, and general medicine-is critical to ensuring that youths who are in need of mental health care receive appropriate services.     

Why caregivers of people with dementia and memory loss don't use services

OBJECTIVES: To develop a typography of the characteristics of caregivers of community dwelling people with dementia or memory loss who do not use services and empirically investigate the reasons for service non-use. METHOD: The findings of a literature review were used to develop a typography of caregivers' non-use of services. This typography was applied to a sample of community-based caregivers. RESULTS: One in three caregivers were using no services and one in four only one service. Despite considerable proportions reporting low levels of life satisfaction and high levels of overload and resentment the main reasons caregivers gave for not using services were that they did not consider they needed the services. Other reasons for service non-use included care recipient reluctance to use services, lack of knowledge of services or being in the process of applying for services. Service availability or affordability were not identified as major impediments to service use. Presence of a physical disability and contact with a social worker were associated with service use. CONCLUSIONS: Caregivers of people with dementia incur significant strain and have substantial need for a variety of services. Nevertheless many caregivers were not using support services, mainly because of perceived lack of need or lack of awareness. Better public promotion of services, destigmatising dementia and encouraging referrals from health professionals could help overcome the barriers to service use.     

Predictors of mental health service utilization by people using resources for homeless people in Canada

OBJECTIVE: This study used Pescosolido's network episode model to examine mental health service utilization among impoverished people accessing resources for the homeless in Canada's universal health care setting. METHODS: The sample consisted of 439 people who met DSM-IV criteria for affective or psychotic disorders who were assessed as part of a larger study of resources for homeless or impoverished people in Montreal and Quebec City. Interviews were organized into the framework of four network episode model concepts: sociodemographic characteristics, illness characteristics, illness history, and social network. These blocks of variables were then analyzed in terms of their accuracy in predicting mental health service utilization. RESULTS: Eighty-four percent of the sample were male, the mean+/-SD age was 41+/-12 years, and 36% were homeless at the time of the interview, but nearly half (48%) of the population had been homeless previously. The research shows that each network episode model concept except illness history significantly predicted utilization of mental health services. Female gender, youth, never being homeless (sociodemographic characteristics), presence of antisocial personality disorders within the preceding year, past or current alcohol-related disorders (illness characteristics), hospitalization before the preceding year (illness history), and a larger social support network were related to utilization of mental health services. CONCLUSIONS: In the absence of economic barriers to health care, there are other significant barriers to the use of mental health services for people who live in poverty. A better understanding of these factors will help in meeting the service needs of impoverished mentally ill people.     

Examining Racial/Ethnic Minority Treatment Experiences with Specialty Behavioral Health Service Providers

This study investigated whether satisfaction and helpfulness of treatment by mental health service provider is related to race/ethnicity and psychosocial factors. Data from the National Co morbidity Survey-Replication study, which administered mental health service use questions for the past 12-months (1332), was analyzed. Data were stratified by service provider and analyzed with multiple logistic regressions. Racial/ethnic minorities were generally more likely to be satisfied with services provided by specialty mental health providers compared to white respondents. Racial/ethnic minorities generally perceived the services provided by specialty mental health providers as more helpful than did other racial/ethnic groups. Those who reported high cultural identity were more likely to find their treatment experience less satisfying and less helpful. Greater attention to specialty referrals for racial/ethnic minority groups may fruitfully contribute to improve help-seeking for these groups. The role culture plays in shaping the mental health treatment experience needs to be further investigated.     

Multimodal treatment for ADHD among youths in three Medicaid subgroups: disabled, foster care, and low income

OBJECTIVE: This study compared the use of treatments for attention-deficit hyperactivity disorder (ADHD) among three distinct subpopulations of Medicaid-insured youths who have very different mental health needs and patterns of service use: those with federally documented disability, those in foster care, and those in families with low income. METHODS: This one-year, cross-sectional study of community mental health services used administrative data. Individuals who were younger than 20 years, who were continuously enrolled in one Mid-Atlantic state Medicaid program, and who had two or more medical encounters associated with an ADHD diagnosis in 1998 were identified (N=1,296). Measures of the use of mental health services were the number of different classes of psychopharmacologic medications, the psychopharmacologic regimen, and the combined use of pharmacotherapy and psychotherapy treatments (multimodal treatment). RESULTS: Use of multiple psychopharmacologic agents was greater in the disabled and foster care groups compared with the low-income group. Significantly fewer mental health provider visits, but greater use of stimulant treatment only, were observed in the low-income group compared with the other groups. Youths in the disabled group were significantly more likely than youths in the low-income group, but not more likely than youths in the foster care group, to receive multimodal treatments. Children in foster care were significantly more likely than those in the other groups to use a substance abuse service. CONCLUSIONS: Among a cohort of Medicaid-enrolled youths with ADHD, co-existing psychiatric disorders and complex psychopharmacologic treatments were more common in the disabled and foster care groups than in the low-income group. Youths with disabilities were significantly more likely than youths in the low-income group to receive multimodal treatment.     

Evaluating Project Connect: Improving Juvenile Probationers’ Mental Health and Substance Use Service Access

Project Connect is a multilayered county-specific program aimed at linking juvenile probationers to needed mental health and substance use services. In four NY counties, the intervention included cooperative agreements between probation and mental health authorities, program materials to facilitate referral, in-service training for probation officers, and systematic screening for mental health needs. Charts for 583 Baseline youths were reviewed and compared with 594 youths undergoing intake under Project Connect. Compared to Baseline, under Project Connect, referred youths were 2.7 times as likely to access services, regardless of youth or county characteristics, service availability, or when the intervention took place.     

Use of mental health services in Chile

OBJECTIVE:S: To address the growing burden of mental illness in Latin America, a better understanding of mental health service use and barriers to care is needed. Although many Latin American countries have nationalized health care systems that could potentially improve access to care, significant barriers to care remain. The authors report the results of a study examining mental health service utilization in the general population of Chile. METHODS: The data were drawn from the Chile Psychiatric Prevalence Study, a national household survey of 2,987 persons aged 15 years and older conducted in 1992-1999. As part of the survey, psychiatric diagnoses were obtained by using the Composite International Diagnostic Interview, and respondents were asked about their use of general and mental health care services in the past six months and about their experience of barriers to treatment. RESULTS: More than 44 percent of respondents reported use of any health care services in the past six months, and 20 percent reported use of mental health services. Of the respondents who met criteria for a psychiatric disorder, a large proportion (62 percent) did not receive mental health care. Increasing severity of the psychiatric disorder correlated with increasing frequency of overall help seeking, but only a small proportion of the respondents with a psychiatric disorder sought specialized mental health services. Regional disparities and inequities in access to care were found. In addition, indirect barriers to mental health care, such as stigma and misconceptions about the course of psychiatric disorders, were important deterrents to service utilization, particularly among persons with lower socioeconomic status. CONCLUSIONS: To reduce the burden of mental illness in Chile, additional efforts are needed to address both the direct and the indirect barriers to mental health care, including regional inequities in access to care.     

Racial and ethnic differences in utilization of mental health services among high-risk youths

OBJECTIVE: Racial and ethnic disparities in mental health service use have been identified as a major public health problem. However, the extent to which these disparities may be accounted for by other confounding sociodemographic or clinical predictors of service use (e.g., family income, functional impairment, caregiver strain) is relatively unexplored, especially for youth services. The goal of this study was to test for racial/ethnic disparities in use of a variety of outpatient, inpatient, and informal mental health services among high-risk youths, with the effects of other predictive factors controlled. METHOD: Participants were 1,256 youths ages 6-18 years who received services in a large, publicly funded system of care (including the child welfare, juvenile justice, special education, alcohol and drug abuse, and mental health service sectors). Youths and caregivers were interviewed with established measures of mental health service use, psychiatric diagnoses, functional impairment, caregiver strain, and parental depression. RESULTS: Significant racial/ethnic group differences in likelihood of receiving any mental health service and, specifically, formal outpatient services were found after the effects of potentially confounding variables were controlled. Race/ethnicity did not exert a significant effect on the use of informal or 24-hour-care services. CONCLUSIONS: Racial/ethnic disparities in service use remain a public health problem.