Providing culturally appropriate mental health services for minorities

Research on the use of outpatient mental health services has shown lower rates of utilization by minorities. Barriers include economic considerations, access difficulties, and cultural factors. Promoting the use of outpatient mental health services by minorities can have a positive effect on the overall cost of health and mental health care, as well as increasing access to care and quality of care for minority populations. Advantages and disadvantages of various approaches to providing culturally appropriate programming in mental health services are discussed.     

Changes in Satisfaction with Mental Health Services Among Blacks,Whites, and Hispanics in the Department of Veterans Affairs

This paper presents an analysis of changes in satisfaction of minorities with inpatient mental health services provided by the Veterans Health Administration (VHA) during a period of major system change (1995-2001). Post discharge data from 16,223 veterans who received inpatient VHA mental healthservices at 87 medical centers during this period was examined using hierarchical linear models. Blacks were found to have higher satisfaction levels on most measures over the period of study while the satisfaction of whites and Hispanics were not significantly different. There was little change over the study period in the relative satisfaction of minorities and whites. Changes in patterns of VHA mental health care have not adversely affected the satisfaction of minority veterans.     

Race, psychiatric diagnosis, and mental health care utilization in older patients.

To evaluate the impact of race on mental health care utilization among older patients within given clinical psychiatric diagnoses, the authors examined a retrospective sample of 23,718 elderly veterans treated in Department of Veterans Affairs inpatient facilities in 1994. Significant racial differences in mental health care utilization found over a subsequent 2-year period were related to outpatient (but not inpatient) care; for instance: 1) African American patients with psychotic disorders had significantly fewer outpatient psychiatric visits; and 2) African American patients with substance abuse disorders had significantly more psychiatric visits than Caucasian patients in their respective groups. Although inpatient utilization appeared to be similar among races, findings related to outpatient utilization may be associated with such factors as compliance, treatment efficacy, access to health care, or possible clinician bias.     

Locus of mental health treatment in an integrated service system

OBJECTIVE: Epidemiological surveys suggest that half of mental disorders in the community are treated in general medical settings. This paper examines delivery of mental health services in psychiatric, primary care, and specialty medical clinics in the Department of Veterans Affairs (VA), the largest integrated public-sector health care system in the United States. METHODS: The study examined all outpatient visits to VA clinics between October 1996 and March 1998, a time during which VA policy promoted a shift to a primary care model. For veterans with a primary diagnosis of a mental or substance use disorder who made any visit to a VA psychiatric, primary care, or specialty medical clinic, we compared the locus of care and case mix as well as changes in treatment patterns during the study period. RESULTS: Of 437,035 veterans treated for a mental disorder during the final six months of the study period, only 7 percent were seen for their mental disorders exclusively in primary care and specialty medical clinics. Compared with veterans with mental disorders treated in specialty mental health clinics, those treated in medical clinics had less serious psychiatric diagnoses and made fewer visits. While there was a substantial shift of care from specialty to primary care during the study period, no comparable change in the distribution of care between medical and mental health settings was found. CONCLUSIONS: Treatment patterns in VA clinics differ markedly from those in the private sector. Research is needed to determine whether and how staffing models developed in HMOs and community samples should be extended to these public-sector settings.     

Frequency and Scope of Mental Health Service Delivery to African Americans in Primary Care

This study examines whether African Americans with mental health complaints visit primary care physicians more than psychiatrists, and whether they demonstrate this preference more than do Whites. It addresses also whether when presenting with mental health concerns, African Americans and Whites receive a comparable range of interventions, including psychotropic medications. National estimates using the National Ambulatory Medical Care Surveys conducted in 1995 and 1996 confirmed the first hypothesis: African American did make more mental health-related office visits to primary care physicians than did psychiatrists and they did so more than Whites. Mental health interventions on behalf of African Americans and Whites proved to be similar, except that African Americans were less likely to be provided a psychotropic medication. Because African Americans are especially likely to receive outpatient mental health services from primary care physicians, the lower quality of mental health care occurring in primary care disproportionately affects African Americans. Fewer African American visits resulted in prescribing psychotropic medications, and this corroborated findings by other researchers. More research is needed to understand this disparity.     

Gender and Racial/Ethnic Differences in Use of Outpatient Mental Health and Substance Use Services by Depressed Adults

This study examines depressed adults’ use of mental health services, focusing on Latinos and African Americans. Self-report data for adults meeting CIDI criteria for major depression or dysthymia from the 1997–98 HealthCare for Communities Survey were analyzed. Gender stratified logistic regression models examined the relationship between race/ethnicity and outpatient mental health service use, controlling for sociodemographic, health status, insurance, and geographic characteristics. Latinas and African American women and men exhibited low use of outpatient mental health services. Similar results were observed in an insured subsample. Service use by minorities was more affected by financial and social barriers (e.g., stigma). No gender differences were observed in self-reported barriers to care. Concerted and continued efforts to promote access to mental health services are critical for minority men and women affected by depression; adults may have unmet mental health needs. Other vulnerable populations include older adults especially, men, and men in poor health.     

Predictors of Outpatient Mental Health Service Use—The Role of Foster Care Placement Change

This study examined the relationship between placement change and outpatient mental health service use. It is based on (1) conceptual propositions about the impact of the foster care living context on mental health service use, and (2) empirical knowledge about the adverse consequences of placement change. Results of the study, which were based on a cohort of 570 children in foster care in San Diego County, suggest an association between placement changes in child welfare and use of outpatient mental health services. Specifically, an increase in the number of placement changes predicted a greater rate of outpatient mental health visits. The study further found that children who experienced behavior-related placement changes received more outpatient mental health visits than children who experienced placement changes for other reasons. Follow-up analyses of the 144 children who experienced any behavior-related placement changes further indicated that the rate of outpatient mental health service use almost doubled in the 90 days following the first behavior-related placement change. Findings from this study have implications for the practice, policy and research fields in child welfare as well as mental health.     

Medicaid and African American Outpatient Mental Health Treatment

The present study tested the hypothesis that Medicaid-financed African Americans would be more likely to receive outpatient mental health treatment than African Americans whose treatment was financed by private insurance. The hypothesis was confirmed: when compared with privately insured persons eligible for care under either fee-for-service or managed care, the Black–White gap in outpatient service use was significantly smaller under Medicaid. There was no racial difference in outpatient treatment rates among the uninsured. The often-noted difference between Blacks and Whites in the likelihood of receiving outpatient mental health treatment is confined largely to the privately insured.     

Family burden, participation in care and mental health--an 11-year comparison of the situation of relatives to compulsorily and voluntarily admitted patients

SUMMARY The changes in family burden and participation in care of relatives to both voluntarily and compulsorily admitted patients were investigated as part of a longitudinal study of the quality of the mental health services in a Swedish county performed between 1986 and 1997. The relationship between the relative's mental health and family burden, participation in care and need of own support was also investigated. The results showed similar and high levels of burden and a non-sufficient participation in care in both periods investigated despite the ongoing changes in the delivery of psychiatric services and a change in the compulsory legislation in Sweden during the period. More relatives experienced an own need of care and support from the psychiatric services in the 1997 investigation. Relatives who experienced mental health problems of their own more often experienced other forms of burden, experienced less participation in the patient's treatment and also more often had own needs of care and support. It is concluded that interventions in families where relatives experience mental health problems will be useful, since a well-functioning network around the mentally ill person has shown to reduce relapse.     

Latino Adults’ Access to Mental Health Care: A Review of Epidemiological Studies

Since the early 1980s, epidemiological studies using state-of-the-art methodologies have documented the unmet mental health needs of Latinos adults in the U.S. and Puerto Rico. This paper reviews 16 articles based on seven epidemiological studies, examines studies methodologies, and summarizes findings about how Latino adults access mental health services. Studies consistently report that, compared to non-Latino Whites, Latinos underutilize mental health services, are less likely to receive guideline congruent care, and rely more often on primary care for services. Structural, economic, psychiatric, and cultural factors influence Latinos’ service access. In spite of the valuable information these studies provide, methodological limitations (e.g., reliance on cross-sectional designs, scarcity of mixed Latino group samples) constrict knowledge about Latinos access to mental health services. Areas for future research and development needed to improve Latinos’ access and quality of mental health care are discussed.     

Differences in mental health outcomes among Whites, African Americans, and Hispanics following a community disaster

A number of studies have assessed the association between race and ethnicity and psychological health status following exposure to a stressful event. However, some of these studies indicate racial and ethnic minorities have poorer mental health relative to Whites, while others show no differences or that minorities may actually have better psychological health. One year after the terrorist attacks on the World Trade Center, we collected data on a random sample of city residents (N = 2368). The dependent variables were posttraumatic stress disorder (PTSD), PTSD symptom severity, major depression, panic attack, and general physical and mental well-being. We categorized our respondents as Non-Hispanic White, Non-Hispanic African American, Dominican, Puerto Rican, and Other Hispanics. Bivariate results indicated racial/ethnic differences for PTSD symptom severity, depression, general physical and mental health, and panic attack. Using logistic regression and controlling for possible confounding factors, most of these associations were rendered non-significant. That is, we found no post-disaster racial/ethnic differences for PTSD, PTSD symptom severity, or physical health. African Americans and Other Hispanics were less likely to meet criteria for major depression or to be classified as unhealthy on the self-report SF-12 mental health scale compared to Whites. Only for panic attack were African Americans and Puerto Ricans more likely to meet criteria for this outcome. Thus, our study found little support for the hypothesis that Latinos or African Americans consistently suffered from poorer psychological and physical well-being in the aftermath of traumatic events, relative to Whites.     

Mental health services under a U.S. national health insurance plan

Sometime during the 1990s, the U.S. Congress could enact legislation that would establish universal access to basic hospital and physician services and, later, create a national health insurance plan. The author explores the potential effect of these programs on state psychiatric facilities; short-term acute psychiatric care facilities, including those under for-profit ownership; mental health professionals; and delivery of patient care. Each year about 63 million uninsured Americans would be eligible for basic health care under a universal access program, and mentally ill patients who are now unable to afford care would then be eligible for limited mental health services. National health insurance, enacted after the universal-access approach fails, is likely to support the current trend of proportionately more ambulatory and less inpatient mental health care. Wealthy Americans are likely to use the national health insurance system but may also use private mental health services, thereby perpetuating the current pluralistic health care delivery system.     

Benefit Limits for Behavioral Health Care in Private Health Plans

Data from a nationally representative sample of private health plans reveal that special lifetime limits on behavioral health care are rare (used by 16% of products). However, most plans have special annual limits on behavioral health utilization; for example, 90% limit outpatient mental health and 93% limit outpatient substance abuse treatment. As a result, enrollees in the average plan face substantial out-of-pocket costs for long-lasting treatment: a median of $2,710 for 50 mental health visits, or $2,400 for 50 substance abuse visits. Plans’ access to new managed care tools has not led them to stop using benefit limits for cost containment purposes.     

Use of mental health and substance abuse treatment services among adults with HIV in the United States

BACKGROUND: The need for mental health and substance abuse services is great among those with human immunodeficiency virus (HIV), but little information is available on services used by this population or on individual factors associated with access to care. METHODS: Data are from the HIV Cost and Services Utilization Study, a national probability survey of 2864 HIV-infected adults receiving medical care in the United States in 1996. We estimated 6-month use of services for mental health and substance abuse problems and examined socioeconomic, HIV illness, and regional factors associated with use. RESULTS: We estimated that 61.4% of 231 400 adults under care for HIV used mental health or substance abuse services: 1.8% had hospitalizations, 3.4% received residential substance abuse treatment, 26.0% made individual mental health specialty visits, 15.2% had group mental health treatment, 40.3% discussed emotional problems with medical providers, 29.6% took psychotherapeutic medications, 5.6% received outpatient substance abuse treatment, and 12.4% participated in substance abuse self-help groups. Socioeconomic factors commonly associated with poorer access to health services predicted lower likelihood of using mental health outpatient care, but greater likelihood of receiving substance abuse treatment services. Those with less severe HIV illness were less likely to access services. Persons living in the Northeast were more likely to receive services. CONCLUSIONS: The magnitude of mental health and substance abuse care provided to those with known HIV infection is substantial, and challenges to providers should be recognized. Inequalities in access to care are evident, but differ among general medical, specialty mental health, and substance abuse treatment sectors.     

Provision of Mental Health Services in South African Substance Abuse Treatment Facilities

To date, South African research has not examined mental health service provision in substance abuse treatment facilities, even though these services improve client retention and treatment outcomes. To describe the extent to which substance abuse treatment facilities in Gauteng and KwaZulu-Natal provinces provide clients with mental health services during the course of treatment and to compare mental health service provision in these settings by type of facility and staff composition. Cross-sectional audits of substance abuse treatment facilities were conducted in Gauteng and KwaZulu-Natal provinces. Data were collected using the Treatment Services Audit Questionnaire. A response rate of 84% was obtained. Few treatment facilities provide clients with access to mental health services. Inpatient facilities are more likely than outpatient facilities to provide clients with access to mental health services. Facilities with for-profit ownership status are more likely than facilities with non-profit status to provide access to mental health care. Based on the above findings, a number of recommendations are made to increase the provision of mental health services during the course of substance abuse treatment.     

Private and Public Ownership in Outpatient Substance Abuse Treatment: Do We Have a Two-Tiered System?

As investor-owned organizations increase their presence in the mental health care sector, questions emerge regarding the effects of ownership type on service delivery. One important question is whether ownership is related to patient access to care for persons requiring treatment for substance abuse problems. Using data from a 1995 national survey of outpatient substance abuse treatment units, the authors investigate whether there are differences in measures of patient access to care among investor-owned, not-for-profit, and public provider organizations. Results indicate investor-owned units cater to and serve a clientele that differs from that of not-for-profit and public units, suggesting the presence of a two-tiered system of substance abuse treatment.     

Shifting to outpatient care? Mental health care use and cost under private insurance.

OBJECTIVE: Concern over rising health care costs has put pressure on providers to reduce costs, purportedly by reducing inpatient care and increasing outpatient care. METHOD: Inpatient and outpatient claims were analyzed for adult users of mental health services (180,000/year on average) from a national study group of 3.9 million privately insured individuals per year from 1993 to 1995. Costs and treatment days per patient were compared across diagnostic groups and stratified by whether patients were hospitalized. RESULTS: Inpatient mental health costs fell $2,507 (30.4%) over the period, driven primarily by decreases in hospital days per patient per year (19.9%), with smaller changes in the proportion of enrollees who received inpatient care (increase of 0.8%) and a decrease in per diem costs (9.1%). Outpatient mental health costs also declined over the period, falling 13.6% for patients also using inpatient services and 14.6% for patients receiving only outpatient care. Patients whose primary diagnosis was mild to moderate depression saw the largest decreases in inpatient cost per patient (42.8%); those diagnosed with schizophrenia experienced the smallest decrease (23.5%). For patients using outpatient services only, those diagnosed with substance abuse experienced the largest decrease in costs (23.5%); those diagnosed with schizophrenia experienced the smallest decrease (8.6%). CONCLUSIONS: Substantial cost reductions for mental health services are primarily a result of reductions in inpatient and outpatient treatment days. Declines in inpatient service use were not accompanied by increases in outpatient service use, even for severely ill patients requiring hospitalization. Managed care has not caused a shift in the pattern of care but an overall reduction of care.     

Care of persons with schizophrenia: a statistical profile

This article presents the latest information available from the National Reporting Program for Mental Health Statistics on the distribution and characteristics of persons with schizophrenia served by organized, specialty inpatient, outpatient, and partial care mental health programs. Results are presented separately for persons under care at one point in time and for persons admitted over a 1-year period, in order to examine the potential for change in each type of care. Findings show that about 900,000 persons with schizophrenia were served in 1986; that inpatient and outpatient programs were relatively equivalent in total numbers served, but that considerably more patient turnover occurred in inpatient programs; and that partial care programs, although small, were evolving as a locus of care for persons with schizophrenia. Some variations were observed among the different types of organizations offering each type of care, and characteristics of clients/patients that could lead to changes in each type of care were evident. Overall, the findings present a useful composite picture of specialty mental health care for persons with schizophrenia. The need for longitudinal, prospective research is noted.     

Managed care organizational complexity and access to high-quality mental health services: perspective of U.S. primary care physicians

This analysis addresses the relationship between perceived access to high-quality specialty mental health and medical services and 2 aspects of managed care organizational complexity at the practice level: 1) gatekeeper requirements for specialty services, and 2) managing multiple contracts. Cross-sectional analysis of a national telephone survey of 7,197 primary care physicians (PCPs) was performed. Access was defined as high-quality specialty services being always or almost always available to the PCP's patients when medically necessary. PCPs rated access to high-quality outpatient specialty mental health services as much lower than that of specialty medical services (28%; 95% confidence interval [CI], 27-29 versus 81%; 95% CI, 80-82). After adjustment for physician, practice, and managed care factors (multiple logistic regression analysis), perceived access to high-quality outpatient mental health services was lowest for practices with the largest number of managed care contracts and when a physician's practice was a "mixed model" with regard to the gatekeeper function. Perceived access to high-quality specialty medical services was not as strongly associated with these practice characteristics. PCPs who interact with a large number of managed care plans and different administrative models may have the most difficulty in obtaining high-quality mental health services for their patients.     

Identifying risk factors and key strategies in linkage to outpatient psychiatric care

OBJECTIVE: The substantial failure of psychiatric patients to engage in outpatient specialty mental health care after an acute hospitalization at a time when managed care companies and others increasingly hold hospitals accountable for outcomes underscores the importance of identifying patients at high risk for not completing referrals. This study explored patient risk factors for not completing referrals and examined the success of several interventions targeted to achieving linkage with outpatient care. METHOD: A clinically detailed, structured form was used in abstracting information from the medical records of 229 inpatients with a primary psychiatric diagnosis. Clinicians and staff at outpatient programs were contacted to determine whether patients completed their referrals. RESULTS: Approximately two-thirds (65%) of the patients failed to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge. At high risk for unsuccessful linkage to outpatient care were patients with a persistent mental illness and those who had no prior public psychiatric hospitalization, were admitted involuntarily, and had longer lengths of stay. Controlling for risk factors, three clinical interventions used during the hospital stay more than tripled the odds of successful linkage to outpatient care: communication about patients' discharge plans between inpatient staff and outpatient clinicians, patients' starting outpatient programs before discharge, and family involvement during the hospital stay. CONCLUSIONS: Effective clinical bridging strategies can be used to avoid unnecessary gaps in the delivery of psychiatric services. Incorporating these strategies into routine care would enhance continuity of care, especially for some high-risk patients.