High and long-term users of the mental health services

Summary Residents of South-Verona who contacted the mental health services in 1983 were traced and followed for a period of 1 year, utilizing a psychiatric case register. Single consulters and long-stay inpatients were excluded from this cohort. A score of service consumption (with subscores for inpatient, day-patient and outpatient care) was calculated for each patient admitted to the study. Seven percent of the patients seeking care in 1 year were high users, having received inpatient as well as day and outpatient care. Using another criterion in classifying the patterns of care, the same sample was divided into long-term and non-long-term users, the former being 9% of the original cohort. The two criteria were then combined to generate four patterns of use of mental health services (high usersand long-term users, neither high nor long-term users, high users only, long-term users only).Using log-linear analysis, a strong association was found between the pattern of service use and diagnosis, occupational status and previous psychiatric contacts. No significant higher-order interaction emerged between these three variables and the pattern of service use.     

Increasing rates of suicide in Western Australian psychiatric patients: a record linkage study.

OBJECTIVE: To investigate the risk of suicide following contact with mental health services and whether it has changed over time. METHOD: Record linkage was used to obtain the records of previous hospital admissions and mental health service contacts for deaths due to suicide in the period 1980-98. Standardized incidence rates were calculated for the general population and for users of mental health services. Proportional hazards regression was used to assess risk factors within the cohort of people with mental health service contact. RESULTS: Suicide risk was significantly increased in users of mental health services (rate ratio 6.66 in males and 7.52 in females). Suicide risk was highest in the first 7 days after discharge from in-patient care, and decreased exponentially with time since discharge. Suicide risk in users of mental health services has increased over the study period. CONCLUSION: These results highlight the importance of adequate follow-up of patients discharged from in-patient services, and the need for adequate resources for community-based services.     

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.     

Community mental health centers: Movement away from the model?

What happens to community mental health centers when federal funding declines and then ends? Analysis of service utilization patterns over a five year period for a cohort of “graduate” community mental health centers indicates two distinct patterns. One group appeared to assure their fiscal viability by maximizing the traditional inpatient, outpatient, and emergency services while cutting back less lucrative services, such as consultation and education, home visits, and partial hospitalization. The other group maintained a balanced mix of all the services, but apparently did so at some risk to their financial status. Implications for the future of community based mental health care are discussed.     

The impact of managed care on cross-system use of mental health services by veterans in Colorado

OBJECTIVES: Some state mental health systems have implemented capitated managed care as a strategy for lowering mental health care costs. There has been concern that this strategy has left vulnerable populations at risk of not being able to obtain adequate care. This study examined whether the advent of managed care in Colorado resulted in lower rates of use of both state and Department of Veterans Affairs (VA) mental health care services (cross-system use). METHODS: A cohort of 10,950 veterans who had used VA mental health services between 1995 and 1997 were studied to determine whether veterans who lived in counties that had implemented managed care were less likely to be cross-system users over time. VA data were matched with state mental health data to determine who was using both types of services. RESULTS: Rates of cross-system use were generally low. Veterans who lived in a county that had implemented managed care were less likely to be cross-system users than veterans who lived in other counties. However, the proportions of cross system users in managed care counties and in other counties did not change significantly over time. Veterans who were cross-system users were more likely to be younger, to live farther away from a VA hospital and closer to a non-VA hospital, and to have received inpatient VA care. CONCLUSIONS: The implementation of managed care in Colorado did not appear to have affected rates of cross-system use of state and VA mental health care.     

Service utilization and cost of community care for discharged state hospital patients: a 3-year follow-up study.

OBJECTIVE: This study examined the mental health service utilization and costs of 321 discharged state hospital patients during a 3-year follow-up period compared with costs if the patients had remained in the hospital. METHOD: The study subjects were long-stay patients discharged from Philadelphia State Hospital after 1988. A longitudinal integrated database on all mental health and medical services reimbursed by Medicaid and Medicare as well as state- and county-funded services was used to construct service utilization and unit cost measures. RESULTS: During the 3-year period after discharge, 20%-30% of the patients required rehospitalization an average of 76-91 days per year. The percentage of rehospitalized patients decreased over time, but the number of hospital days increased. All of the discharged patients received case management services, and a majority also received outpatient mental health care (66%-70%) and residential services (75%) throughout the follow-up period. The total treatment cost per person was approximately $60,000 a year after controlling for inflation, with costs rising slightly over the 3-year period. The estimated cost of state hospitalization, with the use of 1992 estimates, would have been $130,000 per year if the patients had remained institutionalized. CONCLUSIONS: This analysis suggests that most former long-stay patients are able to live in residential settings while receiving community outpatient treatment and intensive case management services at a reduced cost. There is no indication of cost shifting from the psychiatric to the health care sector; however, some cost shifting from the state mental health agency to the Medicaid program has occurred, since most psychiatric hospital care now takes place in community hospitals.     

Long-term use of VA mental health services by older patients with substance use disorders

OBJECTIVE: The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system. METHODS: In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders. RESULTS: Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions. CONCLUSIONS: Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.     

Pattern of care for schizophrenia patients in Granada (Spain): a case register study

AIMS: This study sets out to explore the use flow of mental health services by a cohort of patients with schizophrenia located in Granada (Spain). METHODS: All cases (N = 844) included in the analysis were users of the community mental healthcare public service provided in the area. The Markov chain model was used to calculate the probability of transition from one type of contact with mental health services resources to another type of contact in the next month, over a three-year follow-up. RESULTS: For a given one-month period, for each level of service contact, most patients continued to use the same level of care. CONCLUSIONS: Our results can be interpreted as a reflection of adequate continuity of mental health care provided by the Andalusian community service.     

Long-stay and long-term psychiatric patients in an area with a community-based system of care. A register follow-up study

In South-Verona, where a community-based system of care consonant with the provisions of the Italian psychiatric reform has been operating since 1978, case-register data show that Long-stay inpatient rates are decreasing, while rates of patients treated long-term outside the mental hospital (i.e. those in "continuous care for one year, receiving treatment in the community by the various out-patient and day-patient facilities and in some cases short spells of inpatient care") show a recent increasing trend. Long-stay inpatients on 31.12.1982 have been compared with long-term community patients on the same date. The two cohorts were similar in terms of basic sociodemographic variables and contained a similar proportion of psychotic patients. However, while 88% of the long-stay inpatients were still long-stay after two years, only 45% of the long-term patients in the community remained in long-term treatment over the same period. Using a log-linear model, diagnosis was found to be the variable with the highest association in the long-term cohort with subsequent pattern of use of mental health services.     

Mental Health Factors in the Utilization of Pediatric Primary Care

The relationship of mental health factors to use of pediatric medical care in a 12-month period is examined using cross-sectional and prospective data from a community-based cohort of children (aged 4–8 years at baseline) and their families. Results from this study demonstrate that mother's self-reported mental health is statistically significantly related to the number of pediatric visits. In the cross-sectional analysis, the effect of mothers's mental health on children with 5 or more pediatric visits is moderated by poverty and mothers with depressive symptoms are much more likely than those without such symptoms to have children who are very high service users (10 visits or more). In the longitudinal analysis, an inconsistent pattern of mothers' mental health problems over a 24-month period increases the likelihood of high use in the third year and the persistence of maternal mental health problems increases the likelihood of very high use.     

Trauma-Focused Treatment in a State System of Care: Is It Worth the Cost?

The efficacy of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in treating child traumatic stress inspires nationwide dissemination, yet widespread adoption by state systems of care is lagging. A significant barrier is the cost of implementation and maintenance of evidence-based services. Thus, the current study examined the annual costs of mental health services accrued for 90 publiclyinsured, trauma-exposed children from the time they began participation in a TF-CBT implementation project to 1 year after their admission. These costs were compared to those accrued over that same time period by 90 trauma-exposed control children that were matched by demographics and prior mental health services utilization using a propensity score matching algorithm and provided outpatient treatment as usual. Results indicated that (a) 27.5 % of the total cost was attributed to high-end services utilized by only 1.67 % of children; (b) two times more money was spent on low-end mental health services received by the TF-CBT group than the control group, and (c) five times more money was spent on high-end mental health services received by the control group than the TF-CBT group in that year. These data suggest that providing evidence-based trauma-focused outpatient treatment to children with trauma-related problems may offset the eventual need for services that are more restrictive and costly.     

Mental health outcomes following naltrexone implant treatment for heroin-dependence

Background

Oral naltrexone is an approved treatment for opioid dependence. However, the impact of sustained release naltrexone on the mental health of treated opioid users has not been studied.

Aims

To assess if naltrexone via implant treatment was associated with any change in (i) risk, (ii) rate, and (iii) duration for hospital morbidity related to several categories of mental disorders among treated heroin users.

Method

A cohort of 359 heroin users treated with sustained release naltrexone via implants in Western Australia was retrospectively followed up for mental health related outcomes via a health record linkage system over an average period of 1.78 years post-treatment.

Results

Individual patient's risk for hospital mental diagnoses was not altered after naltrexone implant. On a population cohort level, hospital admission rates related to all mental health problems, except mood disorders, declined significantly post-treatment; however, length of hospital stay did not improve. Overall, young, female patients or those with pre-existing mental illness were more likely than other patients to require hospital care for mental health issues following treatment. Longer period of heroin use was associated with poorer mood outcomes.

Conclusions

Naltrexone implants were not associated with an increased risk for hospitalisation due to mental illness, and in most cases, were associated with a decrease in mental related hospital admission rate.     

Population-based use of mental health services and patterns of delivery among family physicians, 1992 to 2001.

OBJECTIVE: To examine 9-year rates of family physician (FP) and psychiatrist use, as well as patterns of mental health services delivery by FPs. METHOD: We used population-based data from Winnipeg, Manitoba, to construct mutually exclusive cohorts of adults treated for major or minor mental health disorders in fiscal years 1992-1993 to 2000-2001. For each year, we measured patterns of use in this population and patterns of mental health practice among FPs. RESULTS: The treatment prevalence rate was 224 per 1000 in 2000-2001 and 174 per 1000 in 1992-1993, and the rates for major and minor mental health disorders increased over the 9-year period by 15% and 31%, respectively. In 2000-2001, 92% of adults treated for mental illness saw at least one FP, and 45% saw an FP but no psychiatrist. Adults with major or minor mental health disorders visited an FP on average 9.1 and 6.9 times yearly, respectively, and FP visit rates remained relatively stable. There was a gradient in use by socioeconomic status: adults from communities with lower socioeconomic status had the highest rates of use. By 2000-2001, 24% of FPs billed for services related to psychosocial conditions as often as they did for the most frequent conditions seen in primary care. CONCLUSION: Between 1992-1993 and 2000-2001, the study population's patterns of FP and psychiatrist use remained relatively stable. In more recent years, FPs provided more mental health services than in previous years; this related to increased treatment prevalence rather than to increases in use per adult. FPs played a major role in the provision of mental health care.     

The MATCH cohort study in the Netherlands: rationale,objectives, methods and baseline characteristics of patients with (long‐term) common mental disorders

Research in the last decades shows that common mental disorders may be long‐term and severely disabling, resulting in severe mental illness (SMI). The percentage of Dutch SMI‐patients with common mental disorders receiving mental health services is estimated at 65–70%. However, it is unclear which patients in fact become SMI‐patients. We need to know more about the possible course of common mental disorders, understand the origins of chronicity in more detail, and have more insight in related care processes and care use of patients with common mental disorders. The MATCH cohort study is a four‐year multicentre naturalistic cohort study, with yearly assessments in primary, secondary, and tertiary services in three large Dutch mental health services. Socio‐demographics, mental disorders, course and severity of psychopathology, physiological health indicators, neurocognitive functioning, past and present life events, health care use and contact with mental health services, social functioning and quality of life, and recovery and well‐being are assessed. Baseline findings of 283 participating individuals and their key clinicians are described. The sample appears to appropriately represent the distribution of individuals across diagnostic categories in services, and level of care (outpatient, day treatment, inpatient) in the Netherlands and other developed nations. Copyright © 2016 John Wiley & Sons, Ltd.     

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.     

The Impact of Realignment on Utilization and Cost of Community-Based Mental Health Services in California

Decentralization of California's public mental health system under program realignment has changed the utilization and cost of community-based mental health services. This study examined a sample of 75,951 users, representing 1.5 million adults who visited California's public mental health services during a 6-year period (FY 1988–1990 and FY 1992–1994). Regression analysis was performed to examine cost and utilization reduction over time, across regions, and across psychiatric diagnoses. Overall utilization and cost of community-based mental health services dropped significantly after the implementation of realignment. They were significantly lower for (a) 24-hour services in the urban industrialized Southern Region and (b) outpatient services in the agricultural Central Region of the state. Users diagnosed with mood disorders took a greater portion, but were associated with significantly less treatment and cost than other users in the post-realignment period. When local communities bear the financial risks and rewards, they find more efficient methods of delivering community-based mental health services.     

Contact of mental and nonmental health care providers prior to suicide in Taiwan: a population-based study

OBJECTIVE: Higher rates of health care service use prior to suicide were previously reported in Western countries; however, these studies have tended to suffer from small sample sizes. This nationwide, population-based study examines the distribution and patterns of health care service use among suicide victims in Taiwan. METHOD: A retrospective cohort study was conducted using linked population-based data to determine the proportion of health care service use among suicide victims aged 15 years and older within the 1-year and 1-month period prior to their deaths. After adjusting for demographic, socioeconomic and health care indices, the differences in health care service use patterns were assessed for age and sex. RESULTS: Among the 19 426 suicide victims in the sample, 83.1% had used nonmental health care services within the 1-year period prior to their death, while only 22.2% had used mental health care services. Men, and suicide victims aged 55 years and older, were less likely to have had any contact with mental health care professionals prior to their deaths (P < 0.001). CONCLUSIONS: In line with prior studies, similarly high rates and distinct patterns of health care service use were found in Taiwan prior to suicide. These findings will be of practical interest and should support designing appropriate methods of suicide intervention and effective preventive strategies.     

Demand for mental health care and changes in service use patterns in the Netherlands, 1979 to 1995

OBJECTIVE: Mental health services appear increasingly incapable of satisfying the demand for care, which may cause some segments of the population to be less effectively reached. This study investigated the rates of use of mental health services in the Netherlands from 1979 to 1995 and examined whether particular sociodemographic groups made greater or lesser relative use of these services over time. METHODS: Data were derived from the Facilities Use Surveys, a series of Dutch cross-sectional population studies that have recorded household characteristics and service use since 1979. More than 28,000 households were included in the analyses. RESULTS: The overall use of mental health services virtually doubled from 1979 to 1995; a particularly steep rise was seen in the first half of the 1980s. Households that had one parent, that had low income, that were dependent on benefits, and that were younger all had greater odds of using both specialized mental health care (for example, prevention programs for mental health problems and psychotherapeutic and social psychiatric treatment offered by psychologists, psychotherapists, or psychiatrists) and social work services (for example, psychosocial counselling and practical support offered by social workers to people with social problems, such as housing, finances, and psychosocial issues). Households with low education were less likely to use specialized mental health care but were more likely to use social work services. Nonreligious households and urban households were more likely to use specialized mental health care and were equally likely to use social work services. Overall, these relative use patterns did not change over time. CONCLUSIONS: Despite greater pressures on mental health services and the many changes in service delivery in recent decades, relative patterns of help seeking and referral to mental health services have not varied systematically over time.     

EPA guidance on building trust in mental health services

PurposeTo advance mental health care use by developing recommendations to increase trust from the general public and patients, those who have been in contact with services, those who have never been in contact and those who care for their families in the mental health care system.MethodsWe performed a systematic literature search and the retrieved documents were evaluated by two independent reviewers. Evidence tables were generated and recommendations were developed in an expert and stakeholder consensus process.ResultsWe developed five recommendations which may increase trust in mental health care services and advance mental health care service utilization.DiscussionTrust is a mutual, complex, multidimensional and dynamic interrelationship of a multitude of factors. Its components may vary between individuals and over time. They may include, among others, age, place of residence, ethnicity, culture, experiences as a service user, and type of disorder. For mental health care services, issues of knowledge about mental health services, confidentiality, continuity of treatment, dignity, safety and avoidance of stigma and coercion are central elements to increase trust.ConclusionEvidence-based recommendations to increase mutual trust of service users and psychiatrists have been developed and may help to increase mental health care service utilization.     

Does Closing Inpatient Beds in One Public Mental Health System Result in Increased Use of Hospital Services in Other Systems?

This study of users of Department of Veterans Affairs (VA) behavioral health services examines changes in their use of non-VA inpatient services from 1994 to 1997, a period of extensive VA bed closures. Data on service use were obtained on New York State residents who used VA behavioral health services and on residents who were hospitalized for behavioral health care at community general hospitals and state mental hospitals. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between VA mental health and non-VA inpatient populations without relying on person-specific identifiers. Annually, on average, 6% of VA behavioral health service users were hospitalized in either general hospitals in New York State or state mental hospitals: 4% of psychiatric patients, 10% of substance abuse patients, and 11% of dually diagnosed patients. Overall rates of cross system use did not change significantly from 1994 to 1997. Cross-system use of inpatient services is limited and was not affected by the closure of one-third of all VA mental health beds, most likely because of an increased supply of VA outpatient services.