Health care utilization by persons with severe and persistent mental illness

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

Acute and chronic psychiatric care: Establishing boundaries

Despite advances in psychiatry, a proportion of those with mental illness have episodes of severe illness, and a few of these patients may attain only partial recovery. In this respect, mental illness is similar to physical illness and systems of acute and chronic care are essential. As mental health care financing and delivery systems undergo further flux and reform, we will require clear, consensually developed definitions of levels of care, especially because of the complexities created by a legacy of a 2-tiered, public and private mental health system. This paper first will offer definitions and examples of acute and chronic illness and care. We will also address certain problems inherent to such a classification. We will then consider principles of an potential plans for a system of financing and care for the chronically mentally ill. Two existing plans will be reviewed as illustrations of innovations in chronic care. As health reform changes the financing and delivery of care for the mentally ill, an opportunity exists to integrate public and private monies and services and to improve upon the care of the acutely and chronically mentally ill.     

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.     

An analysis of the definitions of mental illness used in state parity laws

OBJECTIVE: Thirty-four states have enacte mental health parity laws that require a health plan, insurer, or employer to provide coverage for mental illness equal to that for physical illness. This study analyzed definitions of mental illness used in state parity laws, identified factors influencing the development of these definitions, and examined the effects of different definitions on access to care for persons with mental illness. METHODS: Specific language in each state's parity legislation was analyzed. Interviews were conducted with policy makers, mental health providers, advocates, and insurers to determine factors influencing a state's definition. Current definitions of mental illness used in the clinical literature and in federal policy were reviewed and compared with definitions used in state parity laws. RESULTS: The definitions of mental illness used in state parity legislation vary significantly and fall into one of three major categories: "broad-based mental illness," "serious mental illness," or "biologically based mental illness." To define each of these categories, state legislatures do not rely on clinically accepted definitions or federal mental health policy. Rather, influenced by political and economic factors, they are developing their own definitions. CONCLUSIONS: Definitions of mental illness in state parity laws have important implications for access, cost, and reimbursement; they determine which populations receive a higher level of mental health services. Future research must qualitatively examine how state definitions affect the use and cost of mental health services.     

Can Assertive Community Treatment Remedy Patients Dropping Out of Treatment Due to Fragmented Services?

Previously, many patients with severe mental illness had difficulties to engage with fragmented mental health services, thus not receiving care. In a Dutch city, Assertive Community Treatment (ACT) was introduced to cater specifically for this group of patients. In a pre–post comparison, changes in mental health care consumption were examined. All mental health care contacts, ACT and non-ACT, of patients in the newly started ACT-teams were extracted from the regional Psychiatric Case Register. Analyses of mental health care usage were performed comparing the period before ACT introduction with the period thereafter. After the introduction of ACT, mental health care use increased in this group of patients, although not all patients remained under the care of ACT teams. ACT may succeed in delivering more mental health care to patients with severe mental illness and treatment needs who previously had difficulties engaging with fragmented mental health care services.     

Connecting Mentally Ill Detainees in Large Urban Jails with Community Care

Large urban jails have become a collection point for many persons with severe mental illness. Connections between jail and community mental health services are needed to assure in-jail care and to promote successful community living following release. This paper addresses this issue for 2855 individuals with severe mental illness who received community mental health services prior to jail detention in King County (Seattle), Washington over a 5-year time period using a unique linked administrative data source. Logistic regression was used to determine the probability that a detainee with severe mental illness received mental health services while in jail as a function of demographic and clinical characteristics. Overall, 70 % of persons with severe mental illness did receive in-jail mental health treatment. Small, but statistically significant sex and race differences were observed in who received treatment in the jail psychiatric unit or from the jail infirmary. Findings confirm the jail’s central role in mental health treatment and emphasize the need for greater information sharing and collaboration with community mental health agencies to minimize jail use and to facilitate successful community reentry for detainees with severe mental illness.     

Regular sources of medical care among persons with severe mental illness at risk of hepatitis C infection

OBJECTIVE: An estimated 19.6 percent of persons with severe mental illness are infected with the hepatitis C virus. Given the pressing need to identify and treat persons with severe mental illness who are at risk of hepatitis C infection and transmission, the authors sought to estimate the proportion of hepatitis C-positive and -negative persons with severe mental illness who have a regular source of medical care. METHOD:S: Data for this study were obtained from 777 adults with severe mental illness at four diverse geographic sites at which respondents with severe mental illness participated in a structured interview and laboratory testing for HIV infection, AIDS, hepatitis B infection, and hepatitis C infection. RESULTS: In bivariate analyses, 54.2 percent of hepatitis C-positive and 62.5 percent of hepatitis C-negative study participants with severe mental illness had a regular source of medical care. In multivariate analyses in which potential confounders were statistically controlled for, hepatitis C-positive persons with severe mental illness were less than half as likely as hepatitis C-negative persons to have a regular source of care. Being older, married, insured, or employed or having self-reported health problems increased the likelihood of receiving care. Being black or male or living in a community with high exposure to community violence lowered those odds. CONCLUSION: There is an urgent need to improve access to medical care for persons with severe mental illness, especially those who may be at high risk of or are already infected with the hepatitis C virus.     

Severely Mentally Ill Patients with and Without Substance Use Disorders: Characteristics Associated with Treatment Attrition

We aimed to describe characteristics associated with attrition for patients in community mental health treatment with chronic mental illness with and without substance use disorders. Baseline assessments included symptom severity, treatment satisfaction, social support, and a structured diagnostic interview. Treatment attrition was assessed at six months. At six months, 36% of the dual diagnosis group (n = 25), and 61% of the mental illness alone group (n = 23) were lost to follow-up. Attrition in the dually diagnosed group tended to be associated with less satisfaction with treatment, and higher mean symptom scores. There were no characteristics associated with attrition in the group of patients with mental illness alone. However, client satisfaction tended to increase among the mental illness alone patients that were successfully followed. The dually diagnosed group that remained in treatment had a significantly lower mean treatment satisfaction score than the mental illness alone group at six months. This type of investigation should aid in patient care and evaluation of treatment programs for persons with severe mental illness and co-occurring substance use disorders.     

Health maintenance organizations and persons with severe mental illness

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

Failure to seek health care among the mentally ill

This study describes failure to seek health care among 673 new adult clients seeking mental health services in the San Francisco Bay area. Overall, 49% (n = 328) reported a failure to seek health care they believed was needed in the past year. People with dual diagnosis, severe depression, chronic physical illness, fear of coercive treatment, private insurance, and no insurance were more likely to fail to seek health care. Greater use of private physicians decreased the odds of failure to seek health care. These findings highlight the need to target groups at risk for failure to seek health care and the need to design nonthreatening programs to improve health access for people with mental illness.     

HIV and people with serious mental illness: the public sector's role in reducing HIV risk and improving care.

OBJECTIVE: The paper discusses issues related to the detection, prevention of transmission, and treatment of human immunodeficiency virus (HIV) infection among persons with serious mental illness and suggests ways public mental health systems can address these issues. METHODS: MEDLINE was searched from 1980 through 1998, and all pertinent references were reviewed. RESULTS: Persons with severe mental illness are at greatly increased risk of HIV infection due to increased likelihood of high-risk sexual behaviors and injection drug use. The formidable barriers to detection and effective treatment of HIV that exist in this population can be attributed to the unique characteristics of this population, lack of knowledge and expertise among mental and physical health care providers, and fragmented mental and physical health care systems. CONCLUSIONS: In the last five years, treatments for HIV that are far more efficacious than earlier treatments have become available, making it more important for HIV infection be detected and treated among persons with serious mental illness. Public mental health systems need to implement active prevention policies and practices, educate both mental health and physical health care providers about key treatment issues, and develop effective linkages between mental and physical health care providers and systems.     

Differences in HIV care between patients with and without severe mental illness

OBJECTIVE: This study explored how HIV care differs for infected persons with and without severe mental illness. METHODS: Data were obtained through interviews with and chart review of 295 patients with severe mental illness and HIV from public mental health agencies in Los Angeles County and New York City. Data were compared with data from 1,294 HIV patients without severe mental illness from a separate national probability sample. Measures were difficulty obtaining care, whether patients recommend their HIV care provider, hospital problem score, functional health status, and disability days. RESULTS: In Los Angeles, HIV patients with severe mental illness were more likely than those without severe mental illness to have difficulty obtaining care (p<.001); to not recommend their provider (10% versus 5%, p=.007); and to have problematic hospital care (p=.001), poor health status (p=.001), and more disability days (p<.001). In New York City, HIV patients with severe mental illness were more likely than patients without severe mental illness to have difficulty obtaining care (p=.002) and not recommend their provider (p=.02). The relationship between severe mental illness and health status in Los Angeles and access in New York City became insignificant after adjustment for sociodemographic factors, drug use, and CD4 cell count. Further adjustment for higher case management rates among HIV patients with severe mental illness reduced disparities only in the West. CONCLUSIONS: Patients with severe mental illness experienced more problems with HIV care than patients without severe mental illness, although high case management rates for patients with severe mental illness may have offset some problems.     

Mental health need and access to mental health services by youths involved with child welfare: a national survey

OBJECTIVE:This study assessed the relationship between the need for and use of mental health services among a nationally representative sample of children who were investigated by child welfare agencies after reported maltreatment. METHOD: Data were collected at study entry into the National Survey of Child and Adolescent Well-Being and were weighted to provide population estimates. RESULTS: Nearly half (47.9%) of the youths aged 2 to 14 years (N = 3,803) with completed child welfare investigations had clinically significant emotional or behavioral problems. Youths with mental health need (defined by a clinical range score on the Child Behavior Checklist) were much more likely to receive mental health services than lower scoring youth; still, only one fourth of such youths received any specialty mental health care during the previous 12 months. Clinical need was related to receipt of mental health care across all age groups (odds ratio = 2.7-3.5). In addition, for young children (2-5 years), sexual abuse (versus neglect) increased access to mental health services. For latency-age youths, African-American race and living at home significantly reduced the likelihood of care. Adolescents living at home were also less likely to receive services, whereas having a parent with severe mental illness increased (odds ratio = 2.4) the likelihood of service use. CONCLUSIONS: Routine screening for mental health need and increasing access to mental health professionals for further evaluation and treatment should be a priority for children early in their contact with the child welfare system.     

The mental health needs of the severely physically disabled

Severely physically disabled individuals, advocates for the disabled, and rehabilitation and mental health professionals were surveyed to determine their perceptions of the need for services for 12 mental health problems encountered by persons with physical disability and the kinds of services needed. All groups surveyed agreed that vocational, social-interpersonal, personal-emotional, self-concept, and marital-family problems were in greatest need of services, but their perceptions of the extent of service need for each of the 12 problems differed significantly. The groups unanimously perceived rehabilitation counseling as the most needed service but differed significantly in their perception of the extent of service need for other services that were also highly rated, such as family, group, and individual therapy; peer counseling; respite care; and social skills training. The groups unanimously agreed that services designed to treat major mental illness were the least needed.     

Mental health care providers' perception of giving culturally responsive care to American Indians

PROBLEM: To determine if mental health care providers delivering culturally responsive care to American Indians experiencing severe and persistent mental illness. METHODS: This qualitative study used grounded theory. Eleven mental health care providers and two administrators participated on two American Indian reservations with two different tribal affiliations. FINDINGS: Preliminary findings indicate the ability of providers to be culturally responsive varied based on an awareness of their personal culture and of the diversity within the American Indian culture. CONCLUSIONS: Mental health providers need to develop a higher level of awareness of diversity within their culture, which is possible through greater connection to their own culture. Future research should ask clients what mental health services would be culturally responsive.     

Shared decision-making preferences of people with severe mental illness

OBJECTIVE: Perceived roles and preferences were explored for shared decision making among persons with severe mental illnesses. METHODS: In this pilot study, 30 adult clients with severe mental illness in a community mental health center were surveyed about decision making regarding psychiatric medications, rehabilitation, and general medical care. RESULTS: Clients generally expressed a desire for greater participation in decisions about psychiatric care than they currently experienced. Regarding use of new psychiatric medications, 23 persons (77%) preferred autonomous or shared roles, but only 11 (37%) rated their current roles as more than passive (z=-2.83, p=.005). Clients were less likely to prefer a passive role in medication decisions about psychiatric care than about general medical care (seven persons, or 23%, versus 23 persons, or 77%; z=-3.01, p=.003). CONCLUSIONS: Most clients with severe mental illnesses prefer shared decision making, particularly in relation to their mental health care.     

Late consequences of chronic pediatric illness.

There are many challenges in coping with and adapting to life with a chronic disease, and increased survival cannot be assumed to be associated with increased quality of life. A recent systematic review shows there is wide variation in outcomes depending on the definitions and measurements used to estimate the prevalence of chronic health conditions, making the impact of disability on children's health and social functioning difficult to assess; various authors have called for an international consensus about the conceptual definition of chronic health conditions in childhood. It frequently is difficult to determine if problems in psychosocial functioning are caused by the underlying illness, by treatment, or by the resultant effects of either illness or treatment on physical growth or cognitive development. Assessment and treatment of mental health should be an integral component of the comprehensive care of chronically ill children and adolescents. Transition of care is an important process that addresses significant changes from child-oriented to adult-oriented care. Adults who have chronic health conditions should continue to be evaluated periodically for late consequences of the childhood illness and early medical care, and attention should be paid to their ongoing psychosocial, psychiatric, educational, and vocational needs.     

The WHO collaborative study on strategies for extending mental health care, II: The development of new research methods

Teams in seven developing countries under sponsorship of the World Health Organization have been carrying out collaborative operational research on providing mental health care through primary health care services. New techniques of identifying mental disorders in children and adults have been developed and tested. Methods of assessing the skills and attitudes of health workers toward mental health work and of gauging community attitudes toward mental illness have also been developed. Results have been directly applied in planning better mental health care. The authors conclude that cross-cultural collaborative research is effective in improving mental health care for those in greatest need.     

Assessment of mental health problems in people with intellectual disabilities

Although it is widely accepted that individuals with intellectul disabilities face an increased vulnerability to developing mental health problems, there is currently a lack of agreement about the most appropriate form of assessment. When applied to people with intellectual disabilities, there is no consensus about which problems should be included in the term "mental health problem," and identifying mental illness is far from straightforward. The adoption of standardized classification systems assumes that individuals with intellectual disabilities have adequate linguistic skills and they present mental health problems in the same way as members of the general population. Yet, individuals with intellectual disabilities are less likely to fulfill verbal expectations that are the basis of current classification systems and many exhibit problem behaviors incompatible with existing criteria. Nevertheless, accurate diagnosis provides a clear direction for interventions. Although there is currently a lack of consensus about which instruments are most effective, the routine use of valid and reliable assessment and monitoring tools may significantly improve the quality of research and care. The complexity of factors influencing the mental health of individuals with intellectual disabilities has implications for how these needs can be effectively met. Clearly, diagnostic classification provides only partial guidance to morbidity and the quality of life experienced and mental health services increasingly adopt a problem-based, "biopsychosocial" approach to assessment and treatment delivered by multidisciplinary teams. The most basic and vital role of carers within this context is the awareness that a person with intellectual disabilities may suffer from a mental illness. Carers play a central role in recognising possible mental illness, making referrals for further psychiatric assessment and providing diagnostic information and treatment feedback. In the absence of information about the manifestation of mental health problems in individuals with intellectual disabilities, it is likely that the signs of mental illness will be overlooked. Training initiatives, aimed at increasing the ability of care staff to recognise the signs of mental illness and to make informed referral decisions, are vital in ensuring adequate access to mental health services by individuals with intellectual disabilities.