Linking physical and mental health: Comparing users and non-users of mental health services in medical care utilization

Higher medical costs incurred by persons with mental disorders was assessed by comparing users and non-users of mental health services in their use of medical (non-mental health) services. Insurance claims data for 4.8 million persons enrolled in the Federal Employees Plan in 1978 were examined. Policy-related recommendations include the need for coordinated mental and physical health care in primary care settings. In particular, the physical health problems of patients in mental health settings should not be ignored as these may cause or exacerbate distress and reduce the effectiveness of mental health treatment.     

Inequalities in use of specialty mental health services among Latinos,African Americans,and non-Latino whites

OBJECTIVE: The authors investigated whether there are disparities in the rates of specialty mental health care for Latinos and African Americans compared with non-Latino whites in the United States. METHODS: Data were analyzed from the 1990-1992 National Comorbidity Survey, which surveyed a probability sample of 8,098 English-speaking respondents aged 15 to 54 years. Respondents self-identified their race or ethnicity, yielding a sample of 695 Latinos, 987 African Americans, and 6,026 non-Latino whites. Data on demographic characteristics, insurance status, psychiatric morbidity, whether the respondent lived in an urban or a rural area, geographic location, income, and use of mental health services were determined for each ethnic or racial group. Logistic regression analyses were used to examine the associations between ethnic or racial group and use of specialty services, with relevant covariates adjusted for. RESULTS: Significant differences between ethnic groups were found in demographic characteristics, geographic location, zone of residence, insurance status, income, wealth, and use of mental health services. The results indicated that poor Latinos (family income of less than $15,000) have lower access to specialty care than poor non-Latino whites. African Americans who were not classified as poor were less likely to receive specialty care than their white counterparts, even after adjustment for demographic characteristics, insurance status, and psychiatric morbidity. CONCLUSIONS: To understand ethnic or racial disparities in specialty care, the effects of ethnicity or race should be analyzed in combination with variables related to poverty status and environmental context. Further research needs to address the complex construct of social position in order to bridge the gap in unmet need in specialty care.     

Perceived discrimination and mental health among older African Americans: the role of psychological well-being

Objectives: Examine the effect of perceived discrimination (both racial and non-racial) on the mental health of older African Americans and explore the buffering role of psychological well-being (purpose in life and self-acceptance).

Methods: Using an older African American subsample from the National Health Measurement Study (n = 397), multiple regression model by gender was used to estimate the effects of two types of discrimination (every day and lifetime) on SF-36 mental component and mediating role of two concepts of psychological well-being.

Results: With no gender difference on the everyday discrimination, older men experienced more lifetime discrimination than older women. The older men's model found that the depressive symptomology was significantly explained by only everyday discrimination and mediated by self-acceptance. The older women's model was significant, with everyday discrimination and both self-acceptance and purpose in life emerging as mediating variables.

Discussion: The prevalence of institutional lifetime discrimination for older African American men is consistent with previous research. Inconsistency with past research indicated that only everyday discrimination is statistically associated with depressive symptoms. Considering the buffering role of psychological well-being served for mental health problems, practitioners need to emphasize these factors when providing services to older African Americans. Equally important, they must address racial discrimination in mental health care settings.     

Comparison of mental health services in rural and urban Washington

Rural mental health has been an area of increased study in recent years because of unique problems in service of rural areas and underrepresentation of professionals in rural areas. This study collected information from mental health centers in the state of Washington via the state management information system. Rural/urban differences were examined. Results showed that (1) rural therapist were more likely to be generalists than urban therapists, (2) psychologists performed more of the direct service work in rural centers than they did in urban centers, (3) rural centers spent less time in direct activities, and more time in support activities, but did not differ from urban centers in indirect activities, and (4) rural and urban centers did not spend different percentages of time in specific direct, indirect, and support activities with the exception of day treatment where urban centers put more of their time than rural centers.     

Cultural mistrust of white mental health clinicians among African Americans with severe mental illness

This study examined the association between cultural mistrust and beliefs about white mental health clinicians among African-American patients recently admitted to a psychiatric hospital. Self-report and clinician-rated measures of cultural mistrust predicted patients' beliefs about white mental health clinicians. Implications for mental health services to African Americans are discussed.     

Experiences of stigma and discrimination among users of mental health services in Poland

Stigmatization is commonly recognized as one of the main barriers to recovery and to social inclusion of people with mental illnesses. This exploratory study investigated the frequency, type, and sources of actual stigma and discrimination experiences among Polish psychiatric patients. A total of 442 people, treated in various psychiatric health care facilities in Warsaw, were interviewed with the use of the Consumer Experiences of Stigma Questionnaire (CESQ). Qualitative data regarding sources of experienced stigma were also obtained. The respondents reported relatively frequent experiences of stigmatization in everyday situations and interpersonal relations, but they seldom complained of any specific instances of discrimination. The most frequently reported source of stigma was employers and supervisors at work, followed by family, and general community members. Implications of the findings for clinical practice and policy are discussed.     

Bed closures and incarceration rates among users of Veterans Affairs mental health services

OBJECTIVE: This study examined incarceration rates of users of Department of Veterans Affairs (VA) mental health services in 16 northeastern New York State counties between 1994 and 1997-a time of extensive bed closures in the VA system-to determine whether incarceration rates changed during this period. METHODS: Data were obtained for male patients who used inpatient and outpatient VA mental health services between 1994 and 1997 and for men incarcerated in local jails during this period. For comparison, services use and incarceration data were obtained for all men who received inpatient behavioral health care at community general hospitals and state mental hospitals between 1994 and 1996 in the same counties. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between clinical and incarceration populations without relying on person-specific identifiers. RESULTS: Of all male users of VA mental health services between 1994 and 1997, a total of 15.7 percent-39.6 percent of those age 18 to 39 years and 9.1 percent of those age 40 years and older-were incarcerated at some time during that period. Dual diagnosis patients had the highest rate of incarceration (25 percent), followed by patients with substance abuse problems only (21 percent) and those with mental health problems only (11 percent). The rate of incarceration among male patients hospitalized in VA facilities was lower than among men in general hospitals or state hospitals (11.6 percent, 23 percent, and 21.7 percent, respectively), but was not significantly different. No significant increase occurred in the annual rate of incarceration among VA patients from 1994 to 1997 (3.7 percent to 4 percent), despite extensive VA bed closures during these years. CONCLUSIONS: Substantial proportions of mental health system users were incarcerated during the study period, especially younger men and those with both substance use and mental health disorders. Rates of incarceration were similar across health care systems. The closure of a substantial number of VA mental health inpatient beds did not seem to affect the rate of incarceration among VA service users.     

Preferred terms for users of mental health services among service providers and recipients

OBJECTIVE: The terms used to refer to recipients of psychiatric services continue to be controversial. Terms in current use include "patient," "client," "consumer," and "survivor." In this study mental health service recipients and providers were surveyed about their preferences among these terms, and responses were analyzed to identify factors associated with various preferences. METHODS: A total of 550 service providers and 427 recipients at four sites in Ontario-two provincial psychiatric hospitals, a private mental health center, and a psychiatric unit of a general hospital-participated in a brief anonymous survey. RESULTS: Among service providers, 68.4 percent preferred the term "patient," 26.5 percent preferred "client," and.5 percent preferred "consumer." Logistic regression analysis showed that service providers' preferences were associated with age and gender. Among service recipients, 54.8 percent preferred the term "patient," 28.8 percent preferred "client," 7 percent preferred "survivor," and 2.8 percent preferred "consumer." Service recipients' preferences were associated with site, self-reported diagnosis, and employment status. CONCLUSION: The study results indicate lack of universality in preferences for terms for users of mental health services and suggest the need for dialogue about preferred terms between service providers and recipients.     

Use of mental health services among older youths in foster care

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

Use of mental health services by Asian Americans

This study explored the use of mental health services by Asian Americans and other ethnic populations (N=104,773) in California. The authors used linear regression analyses to assess the role of ethnicity and diagnosis in predicting six-month use of services. East Asians used more services than Southeast Asians, Filipinos, other Asians, Caucasians, African Americans, Latinos, and Native Americans, even when severity of illness was taken into account. The findings suggest that aggregating Asian subpopulations into a single group in services research is no longer appropriate. Attention needs to be placed on the needs of Southeast Asians and other Asians, whose service use patterns approximate those of the traditionally most underserved groups, African Americans and Latinos.     

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.     

Posttraumatic stress disorder among African Americans in an inner city mental health clinic

This study examined 184 African-American outpatients in a mental health clinic in the inner city to define the rate of occurrence of traumatic experience and posttraumatic stress disorder (PTSD). This population experienced a high rate of severe trauma. Forty-three percent were found to have PTSD, as measured by the PTSD Symptom Scale. Finally, a chart review of 72 participants found that only 11 percent of participants who met DSM-IV criteria for PTSD also had a chart diagnosis of PTSD. PTSD is a common yet underrecognized and undertreated source of psychiatric morbidity in this urban community of African Americans with low socioeconomic status.     

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.