Perceived unmet need for mental health care for Canadians with co-occurring mental and substance use disorders

OBJECTIVE: Previous analyses demonstrated an elevated occurrence of perceived unmet need for mental health care among persons with co-occurring mental and substance use disorders in comparison with those with either disorder. This study built on previous work to examine these associations and underlying reasons in more detail. METHODS: Secondary data analyses were performed on a subset of respondents to the 2002 Canadian Community Health Survey (unweighted N=4,052). Diagnostic algorithms classified respondents by past-year substance dependence and selected mood and anxiety disorders. Logistic regressions examined the associations between diagnoses and unmet need in the previous year, accounting for recent service use and potential predisposing, enabling, and need factors often associated with help seeking. Self-reported reasons underlying unmet need were also tabulated across diagnostic groups. RESULTS: Of persons with a disorder, 22% reported a 12-month unmet need for care. With controls for service use and other potential confounders, the odds of unmet need were significantly elevated among persons with co-occurring disorders (adjusted odds ratio=3.25; 95% confidence interval=1.96-5.37). Most commonly, the underlying reason involved a preference to self-manage symptoms or not getting around to seeking care, with some variation by diagnosis. CONCLUSIONS: The findings highlight potential problems for individuals with mental and substance use disorders in accessing services. The elevated occurrence of perceived unmet need appeared to be relatively less affected by contact with the health care system than by generalized distress and problem severity. Issues such as stigma, motivation, and satisfaction with past services may influence help-seeking patterns and perceptions of unmet need and should be examined in future work.     

Perceived unmet need for mental health treatment and barriers to care among patients with panic disorder

OBJECTIVE: This study estimated the extent of perceived unmet need for mental health treatment among individuals with panic disorder in primary care settings, investigated the determinants of unmet need, and assessed barriers to care. METHODS: Data were from baseline interviews in a clinical trial that investigated primary care treatment of panic disorder. Participants were asked whether there was any time in the past three months when they did not get as much care for emotional or personal problems as they needed or whether they had delays in getting care. Patients who endorsed unmet need were asked about specific perceived barriers. Logistic regression was used to investigate the determinants of unmet need. RESULTS: Of the 231 patients eligible for the study, 88 (38 percent) endorsed unmet need for emotional or mental health problems. Individuals with worse mental health, those who were more worried about panic, and those without sick pay were significantly more likely to report unmet need. Commonly reported barriers included being unable to find out where to go for help (43 percent), worry about cost (40 percent), lack of coverage by health plan (35 percent), and being unable to get an appointment soon enough (35 percent). CONCLUSIONS: The relatively low level of patient-reported unmet need for mental health treatment among primary care patients with panic disorder suggests that efforts to improve treatment of panic disorder should include patient education about mental illness and the effective treatments available. Although discussion of barriers to care has traditionally centered on stigma and economic factors, the results of this study suggest that simple logistic factors, such as not knowing whom to call for help, are also important barriers.     

Triple jeopardy: impact of partner violence perpetration,mental health and substance use on perceived unmet need for mental health care among men

Objectives  

To examine the relationship between intimate partner violence (IPV) perpetration, serious mental illness, and substance use and perceived unmet need for mental health treatment in the past year among men in the general population using the behavioral model for health-care use (Aday and Anderson in Health Serv Res 9:208–220, 1974; Andersen in A behavioral model of families’ use of health services, 1968; Andersen in Med Care 46:647–653, 2008).     

Diagnosis-related groups for mental disorders, alcoholism, and drug abuse: evaluation and alternatives

Under the new federal prospective payment system, 15 of the 467 diagnosis-related groups (DRGs) cover mental disorders, including alcohol and substance abuse. The authors compare these 15 DRGs with some criteria of an ideal patient classification system. According to their assessment, the DRGs for mental disorders pose no administrative problems, but are not sufficiently homogeneous within categories or heterogeneous between categories. The authors conclude by discussing their own attempt to develop alternative DRGs, based on such variables as age, marital status, and type of treatment as well as on diagnosis.     

Perceived need for alcohol, drug, and mental health treatment

Background To investigate determinants of perceived need for alcohol, drug, and mental (ADM) health treatment and differences in ADM treatment patterns between individuals with perceived need and those without. Methods We used data from a nationally representative telephone survey of 9585 adults conducted in 1997–1998. Logistic regression was used to study the determinants of perceived need and the correlation between perceived need and any ADM treatment, specialty ADM treatment, appropriate care, and medication adherence. Results Just fewer than 37% of individuals with an ADM disorder perceived a need for treatment, while 4.6% of those without an ADM disorder perceived a need for treatment. Women, the young and middle aged, the better educated, those with greater emotional support, and those with greater psychiatric morbidity were more likely to perceive need for ADM services. Perceived need was strongly correlated with receiving ADM treatment, although almost 44% of individuals in ADM treatment did not perceive a need for treatment. Among individuals in ADM treatment, those with perceived need were significantly more likely to receive specialty ADM treatment, but not more likely to be treatment adherent, or to receive appropriate care. Conclusion Substantial levels of unmet need are likely to persist as long as perceived levels of need remain low. Interventions targeting perceived need may hold promise for decreasing unmet need.     

Impact of intimate partner violence on unmet need for mental health care: results from the NSDUH

OBJECTIVES: This study examined risk factors and ethnic differences in the relationship between intimate partner violence and unmet need for mental health treatment (perceived need for but did not receive treatment) in the general population. METHODS: The 2002 National Survey on Drug Use and Health was used; the analysis presented here included black, Hispanic, and non-Hispanic white women ages 18 to 49 who were cohabiting (N=7,924). Logistic regression was used to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs). RESULTS: Victims of partner violence were twice as likely as nonvictims (AOR=2.11, CI=1.41-3.16) overall to report unmet need, after analyses controlled for socioeconomic factors and substance abuse. In ethnic-specific models, only Hispanic and non-Hispanic white women who experienced partner violence were more likely than their nonabused counterparts to report unmet need for treatment (AOR 4.11, CI=1.34-12.60, and AOR=2.12, CI=1.34-3.35, respectively). CONCLUSIONS: This study suggests that women who experienced partner violence, especially Hispanic women, are at increased risk of not receiving needed mental health care. These findings highlight the need for culturally sensitive and specific outreach about the effects of partner violence on women's mental health and how to access these services.     

Measuring trends in mental health care disparities, 2000 2004

OBJECTIVE: This study measured trends in disparities in mental health care by use of an improved method that applies the Institute of Medicine (IOM) definition of racial-ethnic disparities. METHODS: Data from the 2000-2001 and 2003-2004 Medical Expenditure Panel Surveys were used to estimate trends in two global measures of racial-ethnic disparities in mental health care: having any mental health visit and total mental health care expenditure in the past year. Disparities between African Americans, Hispanics, and white Americans were examined by applying a new methodology based on the IOM definition of racial disparity that adjusts for health status and allows for mediation of racial-ethnic disparities through socioeconomic factors. Results found by use of this measure are contrasted with unadjusted means. RESULTS: African-American-white and Hispanic-white disparities in any use of mental health care worsened from 2000-2001 to 2003-2004 when the IOM definition was used; however, these trends were not evident in the unadjusted comparison. No significant African-American-white disparities were found in total mental health expenditures. Hispanic-white disparities in total mental health expenditures were significant within each time period and increased between 2000-2001 and 2003-2004. CONCLUSIONS: The mental health care system continues to provide less care to persons in African-American and Hispanic minority groups than to whites, suggesting the need for policy initiatives to improve services for these minority groups. Future efforts at identifying trends in disparities in mental health services should use methodologies that adjust for health status and allow socioeconomic factors to mediate differences.     

Longitudinal patterns of alcohol, drug, and mental health need and care in a national sample of U.S. adults

OBJECTIVE: Use of longitudinal data can help clarify the extent of persistent need for services or persistent problems in gaining access to services. This study examined the level of transient and persistent need and unmet need over time among respondents to a national survey and whether need was met by provision of mental health services or resolved without treatment. METHODS: Data from the longitudinal Health Care for Communities (HCC) household telephone survey were used to produce joint distributions of need status and care for two periods (wave 1 data collected in 1997 to 1998 and wave 2 data collected in 2000 to 2001; N=6,659). Perceived need was measured as self-report of need for help with a mental or substance use problem. Probable clinical need was assessed with the Composite International Diagnostic Interview, the Alcohol Use Disorders Identification Test, and the 12-item Short Form Health Survey. RESULTS: High levels of persistent unmet need for care (44 to 52 percent) were found among respondents who had probable clinical need in wave 1. Although a majority of those with need received some care, an equal proportion (about 30 percent) of those with perceived need only or probable clinical need in wave 1 did not receive any care. A substantial portion of need (22 to 26 percent) appears to have resolved without treatment, which may suggest high levels of transient need. CONCLUSIONS: Persistent patterns of unmet need represent important targets for policy and programs that can improve utilization, including outreach, education, and improved insurance coverage.     

Ethnic disparities in mental health and educational attainment: comparing migrant and native children

STUDY BACKGROUND AND AIMS: Ethnic disparities in mental health in adolescence may play a role in the development of ethnic disparities in educational attainment. The aim of this study was to assess the contribution of ethnic disparities in mental health problems in adolescence to ethnic disparities in educational attainment in adulthood. METHODS: We followed two community samples of respectively 486 Dutch native and 168 Turkish migrant adolescents (11-15 years old) into adulthood (21-25 years old). Mental health was measured in adolescence, and educational attainment was assessed in adulthood. The contribution of mental health disparities to educational disparities was estimated by the degree of attenuation of the odds ratio (OR) for low education after adjustment for mental health problems. RESULTS: Adult Turkish men more often had attained lower education than Dutch men (OR 1.81 (1.01-3.25)). Additional adjustment for mental health problems during adolescence did not change the OR. In Turkish women, however, the OR was 1.94 (1.04-3.62), and adjustment for mental health problems lowered it by 96% to 1.04 (0.51-2.14). The contribution was mostly due to ethnic disparities in internalizing problems. CONCLUSION: In women, but not in men, ethnic disparities in mental health, especially internalizing problems, were a strong predictor for the development of ethnic disparities in educational attainment. Prevention or treatment of internalizing problems among Turkish girls will probably contribute to the prevention of educational disparities.     

Attention deficit disorder, alcoholism, and drug abuse: MMPI correlates.

Earlier research had demonstrated that alcoholics with attention deficit disorder residual type (ADDRT) differ from other alcoholics on the Minnesota Multiphasic Personality Inventory (MMPI). The purpose of this study was to explore the influence of drug abuse on the relationship of ADDRT and alcoholism as reflected on the MMPI. Groups of 48 male alcoholics, 28 ADDRT alcoholics, 25 ADDRT alcohol and drug abusers and 18 alcohol and drug abusers were all administered the MMPI. Significant differences were found between the alcoholic and ADDRT alcoholic groups on scales Pd, Sc, Si, F, and K. For the ADDRT alcohol and drug abusers versus the alcohol and drug abuser groups, they differed on scales K, Hs, D, Pd, Pa, Pt, Sc, Si, F, K, and L.     

Perceived need for mental health care among non-western labour migrants

Background  There is a supposed higher prevalence of common mental disorders among many migrant groups. At the same time, problems are reported regarding underutilisation of mental health services by migrants. Since perceived need for care is a powerful predictor of actual care utilisation, we aimed to study the hypothesis that, given the same level of mental morbidity, non-Western migrants would perceive less need for mental health care than ethnic Dutch residents. Additionally, we studied the extent to which needs are met in both groups, as well as several possible barriers to care. Methods  A cross-sectional study with data from the 2004/2005 Amsterdam Health Monitor. Data were complete from 626 ethnic Dutch and non-Western (Turkish and Moroccan) labour migrants. Respondents participated in a structured interview in their own language, which included the perceived need for care questionnaire (PNCQ) and the composite international diagnostic interview (CIDI) version 2.1 for anxiety and depressive disorders. Results  Perceived need was much higher among Turkish migrants. Among Moroccans the perceived need was comparable to ethnic Dutch. Turkish migrants also reported that needs were met less often than ethnic Dutch. Differences were explained by a higher prevalence of common mental disorders and higher symptom levels among Turkish. When differences in mental morbidity were taken into account, Moroccans perceived less need for information, drugs, referral to specialised mental health care, or for counselling. The most important barrier to care in all ethnic groups was the preference to solve the problem on one’s own. Conclusion  In case of similar mental morbidity, perceived need for care was lower than among ethnic Dutch. The results did not support the hypothesis that in case of similar mental distress, needs of migrants were less often met than needs of ethnic Dutch.     

Epidemiologic assessment of overmet need in mental health care

The traditional purpose of psychiatric epidemiologic surveys has been the assessment of mental illness and, by implication, the need for care. Previous research has focused on unmet need, defined as those who meet caseness but do not receive care, but has rarely examined the converse. Since survey respondents receiving care but not meeting caseness have been found to represent up to one-half of mental health service users, this is a significant service delivery issue. The data are drawn from the Mental Health Supplement to the Ontario Health Survey (the Supplement), a household survey of 9,953 respondents, which used the University of Michigan's version of the Composite International Diagnostic Interview (UM-CIDI) as its diagnostic instrument. Community residents who used formal mental health services in the past year but who did not have a concurrent UM-CIDI/DSM-III-R (Diagnostic and Statistical Manual 3, revised) diagnosis were defined as treated without CIDI disorder. Their need for care was evaluated by comparing them to treated depressed and healthy respondents, using indicators of functional impairment, vulnerability to developing disorder, and risk of relapse. The match between need and care levels was examined by comparing their type and intensity of use with those of the treated depressed. Results present strong evidence for conceptualizing need as continuous, rather than discrete. The results for the group defined as treated without CIDI disorder were consistently between those for the other two groups (with the treated depressed always showing the highest need) on all indicators as well as on a summary need index. However their type and intensity of service use appeared to be unrelated to their level of need. Although some of the treated without CIDI disorder group may require preventive or follow-up treatment, the need for service for others is not as convincingly demonstrated. Outcome studies are needed to provide comparative data to describe more fully the problems experienced by this group and indicate whether treatment is helpful. In an age of fiscal restraint, when resource reallocation (rather than generation of new resources) is the likely scenario, such close examination of the fit between need and care is critical if services are to be targeted appropriately.     

Perceived need for mental health care and barriers to care in the Netherlands and Australia

Purpose  

This study of Australian and Dutch people with anxiety or depressive disorder aims to examine people’s perceived needs and barriers to care, and to identify possible similarities and differences.     

Translating research into action: reducing disparities in mental health care for Mexican Americans

This article describes a case study in which epidemiologic research findings were translated for multiple stakeholders and applied to reduce disparities in mental health services for Mexican Americans in Fresno County, California. The aims of this evidence-based process were to educate the community and mobilize action, translate research for multiple stakeholders to inform practitioners and policy makers about the need for improved mental health care for minorities, and effect regional policy changes to increase and improve the availability, accessibility, and appropriateness of mental health care for Mexican Americans. Through this process, a community-driven and consumer-oriented model evolved, which resulted in the allocation of resources to expand mental health services in rural areas of Fresno County. The authors discuss the process of translating research into action, key antecedents to an effective outcome, and lessons learned from the process.