Needs for mental health care and service provision in single homeless people

Background: Specific problems in sampling methodology, case-finding strategies and a standardised needs assessment in mentally ill homeless people have contributed to their being neglected as a mental health care clientele. Method: We assessed a representative sample of homeless people (n=102) in the highly industrialised city of Mannheim (Germany) regarding their prevalence of mental disorders (using the SCID) and their needs for mental health care (using the NCA). Results: We found high prevalences, with 68.6 % of all assessed homeless persons having a current mental disorder. Thus, needs for mental health care were very common, with unmet needs predominating in all problem areas, which was supported by a very weak service utilization. Thus, even in a region with a comprehensive community mental health care network, like the study area, mentally ill homeless people are widely under-provided. Conclusions: Results suggest that the traditional shelter system for homeless people carries most of the mental health care burden for their clientele and must be supported by adequate interventions from community-based mental health care services. A closer connection of both sectors and a better co-ordination of the care offers seems to be a prerequisite for helping to reduce unmet mental health care needs in this specific high-risk group. Accepted: 2 January 2001     

Barriers to mental health service utilization

This study examines the system dimensions of need, barriers to receiving services, and utilization within a single mental health service area. The gap between estimates of service need and service utilization is conceptualized as due to a set of specific barriers covering the access attributes of availability, accessibility, acceptability and affordability.Data from community telephone surveys (N=2183) of mental health need are analyzed to determine the relationship between the system dimensions of need, barriers and utilization. Respondents were able to distinguish among different types of service barriers. Those in the service gap were potentially more influenced by barriers than the rest of the sample, as were, paradoxically, those who had utilized services within the past year. The implications of these findings for service provision and system design are discussed.This research was supported by a grant from the Ohio Department of Mental Health, Office of Program Evaluation and Research.     

Determinants of self-reported mental health and utilization of mental health services in Canada

Research evidence suggests that the prevalence of mental health conditions in Canada has increased while a considerable percentage of people with a mental health issue do not seek professional mental health services. Weighted logistic regression models were used to determine whether age, sex, income, and education predict the self-reported mental health status of Canadians and their odds of utilizing mental health services. This study found clear disparities in reporting mental health and utilization of mental health services. Young adults (aged 25 to 44) have 1.4 times (95% CI: 1.3 to 1.6 times) higher odds of reporting poorer mental health status than seniors (aged 65 or older). Females are 2.7 times (95% CI: 2.3 to 3.1 times) more likely to utilize mental services than males. The lowest income group (<$15,000) has 2.2 times (95% CI: 1.9 to 2.4 times) higher odds of rating poorer mental health status than the highest income group (>$80,000). The least educated group (<high school education) has 1.5 times (95% CI: 1.3 to 1.6 times) higher odds of reporting poorer mental health status than the highest educated group (post-secondary education). However, the highest educated group is 1.6 times (95% CI: 1.3 to 2.0 times) more likely to utilize mental health services than the least educated group. Even in a country that has a universal health insurance system such as Canada, disparities and inequities associated with mental health burden and health care utilization persist, specifically among groups with lower education, lower income, and males.     

A systematic study of mental health services utilization by homeless men and women

Summary Psychiatric illness is overrepresented among the homeless, but mental health services are underutilized in this population in proportion to their needs. The current study was concerned with 900 homeless men and women randomly sampled and systematically interviewed with the Diagnostic Interview Schedule; it focuses on psychiatric and substance abuse rehabilitation service patterns and stated needs of this population in relation to specific psychiatric disorders. Although rates of lifetime treatment utilization were fairly high in comparison with general population utilization patterns, rates of treatment in the current year were low. In particular, outpatient services have been neglected for reliance upon inpatient services. Although the major reason cited for not obtaining treatment by homeless persons with mental illness was lack of insurance and inability to pay for it, having health insurance was not associated with mental health services utilization, nor were other important predictors apparent. Mental health professionals serving mentally ill homeless populations would best serve them by focusing on creative and innovative ways to improve the availability and attractiveness of ambulatory care services.     

Personality correlates of outpatient mental health service utilization

OBJECTIVE: The present paper investigated the relationships between several personality constructs and the use of outpatient mental health services. METHODS: Respondents were from the National Comorbidity Survey (NCS) Part II data set and included those with a past-year mood, anxiety, alcohol/substance use disorder (n=1750). Bivariate logistic regressions were used to examine associations between participants' self-reports of personality traits and outpatient mental health service utilization. Similar multivariate analyses were used to investigate these associations after adjusting for sociodemographic variables and the presence of psychiatric disorders and their comorbidity. RESULTS: The bivariate and multivariate analyses revealed significant positive associations between outpatient mental health service utilization and both Powerful Others Locus of Control and Self-criticism. CONCLUSIONS: These findings suggest that personality traits may play a role in treatment seeking behaviors for mental health problems over and above the presence of psychiatric disorders alone. The assessment of relevant personality constructs has the potential to inform and improve treatment outreach efforts.     

A nurse-led mental health service for people with multiple sclerosis

BackgroundMental health problems are under recognised and under treated in people with multiple sclerosis (MS).MethodA nurse-led project linking MS and mental health services was evaluated. Data on all referrals and management from 2006 to 2008 were collected prospectively.Results127 referrals were received. 82% had depression, 53% had anxiety (45% both). 42% were offered case management; 52% received Cognitive Behaviour Therapy (CBT), 55% required initiation or alteration of psychiatric medications and 19% were referred to secondary care; 16% had made suicidal plans. Significant improvements in depression at 6 months occurred, but not anxiety or fatigue.Clinical implicationsThis service provides a model of mental health provision for patients with long term neurological conditions, in particular MS.     

Gaps in service utilization by Mexican Americans with mental health problems.

OBJECTIVE: The purpose of this study was to ascertain the degree of underutilization of services for mental health problems among urban and rural Mexican American adults. METHOD: A probability sample (N = 3,012) was used to represent the Mexican American population of Fresno County, California, and face-to-face interviews were conducted with the use of the Composite International Diagnostic Interview. Bivariate and multivariate analyses were used to analyze the data on diagnosis and service utilization. RESULTS: Among the respondents with DSM-III-R-defined disorders, only about one-fourth had used a single service or a combination of services in the past 12 months, and Mexican immigrants had a utilization rate which was only two-fifths of that of Mexican Americans born in the United States. Overall use of mental health care providers by persons with diagnosed mental disorders was 8.8%, use of providers in the general medical sector was 18.4%, use of other professionals was 12.7%, and use of informal providers was only 3.1%. According to logistic regression analyses, factors associated with utilization of mental health services included female sex, higher educational attainment, unemployment, and comorbidity. CONCLUSIONS: Immigrants are unlikely to use mental health services, even when they have a recent disorder, but may use general practitioners, which raises questions about the appropriateness, accessibility, and cost-effectiveness of mental health care for this population. Several competing hypotheses about the reasons for low utilization of services need to be examined in future research.     

Patterns of mental health service utilization in a general hospital and outpatient mental health facilities

Purpose Mental health is one of the priorities of the European Commission. Studies of the use and cost of mental health facilities are needed in order to improve the planning and efficiey of mental health resources. We analyze the patterns of mental health service use in multiple clinical settings to identify factors associated with high cost. Subjects and methods 22,859 patients received psychiatric care in the catchment area of a Spanish hospital (2000–2004). They had 365,262 psychiatric consultations in multiple settings. Two groups were selected that generated 80% of total costs: the medium cost group (N = 4,212; 50% of costs), and the high cost group (N = 236; 30% of costs). Statistical analyses were performed using univariate and multivariate techniques. Significant variables in univariate analyses were introduced as independent variables in a logistic regression analysis using “high cost” (>7,263$) as dependent variable. Results Costs were not evenly distributed throughout the sample. 19.4% of patients generated 80% of costs. The variables associated with high cost were: age group 1 (0–14 years) at the first evaluation, permanent disability, and ICD-10 diagnoses: Organic, including symptomatic, mental disorders; Mental and behavioural disorders due to psychoactive substance use; Schizophrenia, schizotypal and delusional disorders; Behavioural syndromes associated with physiological disturbances and physical factors; External causes of morbidity and mortality; and Factors influencing health status and contact with health services. Discussion Mental healthcare costs were not evenly distributed throughout the patient population. The highest costs are associated with early onset of the mental disorder, permanent disability, organic mental disorders, substance-related disorders, psychotic disorders, and external factors that influence the health status and contact with health services or cause morbidity and mortality. Conclusion Variables related to psychiatric diagnoses and sociodemographic factors have influence on the cost of mental healthcare.     

Psychopathology and mental health service utilization by immigrants' children and their families

To investigate the psychopathology of immigrants' children and psychiatric service utilization by the immigrant families, data were collected from the files of all 35 immigrant children seen over a 3-year period at the Community Mental Health Centre of the Athens University Psychiatric Department. Immigrant children were matched by age, gender and intake date with 70 Greek children. Data concerned information about the child's place of birth, current living conditions, parents' country of origin, social and economic situation, occupations and educational status, social insurance, psychiatric history, referral source, diagnostic and therapeutic services rendered, number of sessions and outcome. Utilization of services was assessed 6 months after intake. No significant differences were found regarding family's structure and parents' psychopathology. However, immigrant families had significantly worse economic situations, lower status jobs, worse housing and were usually uninsured. No significant differences were observed regarding service utilization parameters, except concerning 'cooperation with other services' No differences were found regarding frequency or type of psychiatric diagnosis. However, 91% of the immigrant group received a psychosocial diagnosis as opposed to 49% of the Greek group. Immigrant children did not present more serious or diverse psychopathology than did Greek children. Immigrant families had equal levels of service utilization as Greek families. However, it was apparent that immigrant families did not apply for help as readily as their Greek counterparts.     

Factors related to utilization of services for mental health reasons in Montreal, Canada

This study examines factors related to the utilization of services for mental health reasons by Montreal residents. Data were drawn from telephone interviews. A random sample of 893 respondents completed a questionnaire on service utilization and the Diagnostic Interview Schedule Self Administered to assess DSM-III-R psychiatric disorders. Results indicate that 12.8% of the population had used such services in the past year. Medical doctors and psychiatrists, whose services are free of charge under universal health coverage, were consulted, respectively, by 4.1% and 2.0% of respondents. Psychologists, whose services are not free, were seen by 3.4% of respondents. In all, 42.0% of respondents who presented a current diagnosis used services in the past year. The highest proportion of users (48.0%) was found among respondents who presented both current and lifetime diagnoses and among respondents with comorbidity. The choice of caregiver was related also to pattern of disorders: respondents with current and comorbid disorders tended to consult general practitioners, while respondents with lifetime disorders or with lifetime and current disorders favoured specialized care. In line with other studies, self-perception of mental health, gender and marital status were related to utilization; unlike other studies, attitudes and age were not. It is argued that particularities found in this study stem not only from methodological considerations, but also from the configuration of the mental health system in Quebec, where the greater availability of psychologists may facilitate service utilization. Accepted: 28 August 1997     

Psychotropic medication utilization in a child and adolescent mental health service

OBJECTIVES: This study aimed to identify rates and correlates of psychotropic drug utilization in children and adolescents in inpatient and outpatient settings. METHODS: A retrospective chart review examined 122 inpatient and 126 outpatient charts from a metropolitan child and youth mental health service in Brisbane, Australia. RESULTS: Inpatients received more psychotropic medication than outpatients (71% vs. 25%; p < 0.01). Patients receiving medication were older, had longer hospital admissions, and more complex presentations, including history of abuse or suicide attempts and more diagnoses (all p < 0.01). Selective serotonin reuptake inhibitors (SSRIs) were the most frequently used drug class (44% inpatients; 14% outpatients), primarily indicated for mood disorders (31%). SSRIs and newer antidepressants (ADs) were used more frequently in patients with a high suicide risk (p < 0.01). Atypical antipsychotics (APs) were also used (inpatients 23%; outpatients 3%), primarily for behavioral disturbances. Half of those receiving medication (51%) received polypharmacy (>1 concurrent drug), with up to four drugs used at one time. Rates of polypharmacy were highest among patients receiving antipsychotics. CONCLUSIONS: Use of psychotropic medication is frequent in this population. Future research should initially focus on inpatients and intensive treatment settings and examine both safety and efficacy of interventions for depression in young people, atypical antipsychotics for behavioral disturbances, and polypharmacy.     

Depressive symptoms and mental health service utilization in a community sample

Summary This study examines the utilization of health visits for mental health purposes by community respondents with depressive symptoms. Data are drawn from first wave interviews of the Epidemiologic Catchment Area (ECA) project at the Baltimore, Durham, and Los Angeles sites. The results indicate that persons with depressive symptoms, even in the absence of a recent DIS/DSM-III disorder, are at increased risk for making mental health related visits. The risk of visiting a general medical provider or mental health specialist for mental health treatment tends to increase as the number of depressive symptoms increase. Sociodemographic factors including age, racial background, and employment status also influence the risk of making a mental health related visit.     

受助人员社会支持、应付方式与心理健康状况的相关研究

目的探讨受助人员社会支持、应付方式与心理健康状况的相关性。方法随机抽取180名受助人员和172名健康人员,运用社会支持评定量表、应付方式问卷和SCL-90症状自评量表进行问卷调查,并作对照研究。结果受助人员在社会支持总分、客观支持、主观支持和对支持的利用度得分以及解决问题和求助的应付方式得分都明显低于对照组(P<0.01),在自责的应付方式得分和SCL-90总分以及各因子得分明显高于对照组(P<0.01),而在幻想、退避和合理化应付方式得分和对照组差异无显著性(P>0.05)。客观支持、自责、解决问题、合理化4个指标对SCL-90总分有显著性影响(P<0.01)。结论社会支持及应付方式的选择情况与受助人员的心理健康水平有显著性相关。     

Factors associated with mental health service utilization among bipolar youth

OBJECTIVES: This study aims to characterize patterns of mental health service utilization within a sample of bipolar youth. Demographic variables, youth bipolar characteristics, youth comorbid conditions, and parental psychopathology were examined as predictors of treatment utilization across different levels of care. METHODS: A total of 293 bipolar youth (aged 7-17 years) and their parents completed a diagnostic interview, family psychiatric history measures, and an assessment of mental health service utilization. Demographic and clinical variables were measured at baseline and mental health service use was measured at the six-month follow-up. RESULTS: Approximately 80% of bipolar youth attended psychosocial treatment services over the span of 6 months. Of those who attended treatment, 67% attended only outpatient services, 22% received inpatient/partial hospitalization, and 12% received residential/therapeutic school-based services. Using multinomial logistic regression, older age, female gender, and bipolar characteristics, including greater symptom severity and rapid cycling, were found to predict higher levels of care. Youth suicidal and non-suicidal self-injurious behavior, comorbid conduct disorder, and parental substance use disorders also predicted use of more restrictive treatment settings. CONCLUSIONS: Results underscore the importance of assessing for and addressing suicidality, comorbid conduct disorder, and parental substance use disorders early in the treatment of bipolar youth to potentially reduce the need for more restrictive levels of care.     

Factors associated with adolescent mental health service need and utilization

OBJECTIVE: To determine the association of parent, family, and adolescent variables with adolescent mental health service need and utilization. METHOD: Correlates of adolescent mental health service utilization, self-perceived need and unmet need were investigated in a general population sample of 1,120 Dutch adolescents aged 11 to 18 years (78% response rate). RESULTS: 3.1% of the sample had been referred for mental health services within the preceding year, and 3.8% reported unmet need. 7.7% of adolescents at risk for psychopathology, and 17.8% of those indicating a need for help, had been referred. Family stress and adolescent's self-reported problems were most strongly associated with service need and utilization. Internalizing problems, female gender, and low education level were associated with self-perceived unmet need. Adolescent ethnicity and competence in activities and school were associated with service use, but did not influence service need, while the opposite effect was found for adolescent age and parental psychopathology. CONCLUSION: In designing intervention programs aimed at increasing adolescent mental health service use, distinctions should be made between efforts focused at adolescents not recognizing their problems, and those with unmet need.     

Trauma-related mental health needs and service utilization among female veterans

Women constitute a growing segment of the military veteran population and researchers have begun to examine the extent to which their mental health needs are appropriately addressed within the Veterans Affairs (VA) healthcare system. Existing research documents high rates of both military and non-military trauma among female veterans; however, little has been done to examine the extent to which female veterans exposed to trauma receive treatment for trauma-related problems such as posttraumatic stress disorder (PTSD) and substance abuse within the VA system. This article reviews the literature documenting a high rate of trauma exposure among female veterans and examines evidence that trauma-related mental health problems, such as PTSD and substance-use problems, are under-diagnosed and under-treated among female veterans in VA healthcare settings. The few available studies examining general service utilization among female veterans are also reviewed, and implications for future research and clinical practice in the area of female veterans' trauma-related mental health needs and service use patterns are discussed. In order to provide more accurate assessments of female veterans' trauma-related mental health needs, researchers are encouraged to implement comprehensive trauma assessments as well as clinically valid PTSD and substance abuse diagnostic assessments. Researchers are also encouraged to examine the availability and efficacy of both VA and non-VA mental health services to determine the appropriateness of women's VA service use patterns. Clinicians providing VA mental health services for women are encouraged to include comprehensive, behaviorally-specific trauma interviews and diagnostic evaluations for PTSD and substance-related problems in their standard assessment protocols.     

Predictors of incident care service utilisation for mental health problems in the Dutch general population

  Background: The determinants of first-time (`incident') use of primary care and mental health care services for mental health problems have not been previously investigated. Such information is needed to identify new client groups and to gain a better understanding of causal factors. Method: Data were derived from the Netherlands Mental Health Survey and Incidence Study, NEMESIS, a prospective general population study of adults. Potential predictors of care use (psychiatric disorders, burden of illness, sociodemographic characteristics) were recorded in the first wave of the study, and the utilisation of care services in the second wave. Psychiatric diagnoses were based on the Composite International Diagnostic Interview (CIDI) 1.1. Results: Six of the ten indicators linked to the frequent utilisation of care were found not to be associated with incident use: higher age, lower income, living alone, paid employment, mood disorders and anxiety disorders. Four other indicators showed associations with both frequent and incident use: female gender, higher numbers of restricted activity days, poorer social functioning and unmet care needs. Two predictors of incident use only were lower educational attainment and being in treatment for a somatic disorder. Conclusion: New clients who come to primary health care or mental health care services with mental health problems are found in all age groups. They are more likely to be women, to have less education, to be in treatment for a somatic disorder and to have functional problems related to their mental health problems. Accepted: 30 November 2000