Female veterans seeking medical care at Veterans Affairs primary care clinics: psychiatric and medical illness burden and service use

OBJECTIVE: To examine rates of medical and psychiatric disorders among 187 female veterans recruited at four Veterans Affairs Medical Centers (VAMCs), the recognition of such disorders by VAMC care providers, and the use of relevant medical and mental health services by women both within and outside of the VA setting. METHODS: We used a cross-sectional, epidemiological design incorporating self-report measures, structured interviews, and chart reviews to obtain relevant information for analyses. RESULTS: Forty-four percent (43.9%) of women met criteria for at least one psychiatric disorder; 34.0% of these women met criteria for two or more additional psychiatric diagnoses, and concordance rates between interview and chart diagnoses were low. Ninety-five percent (95.2%) of women had a medical condition noted in their charts; 86.6% had two or more additional medical conditions, and a significant number of women had both medical and psychiatric diagnoses. Forty-four percent (43.9%) of women with an identified mental health condition received specialized mental health care by the VA in the past year. CONCLUSIONS: Findings from this study suggest that female veterans treated in VAMCs had significant medical and psychiatric problems, and these women might not be getting their health care needs adequately met through the VA health care system. In light of our findings, we discuss relevant implications and future directions for research.     

Telepsychiatry Consultation for Primary Care Treatment of Children and Adolescents Receiving Child Protective Services in Chile: Mixed Methods Feasibility Study

BackgroundChildren and adolescents living under the supervision of child protective services have complex mental health care needs. The scarcity and uneven distribution of specialized mental health teams in Chile may limit the provision and quality of care for this vulnerable population. Telepsychiatry can address such health inequities.ObjectiveThe objective of this study was to evaluate the feasibility of a telepsychiatry consultation program for primary health care (PHC) treatment of children and adolescents living under the supervision of child protective services.MethodsWe developed a telepsychiatry consultation program for two rural PHC clinics located in central Chile (Valparaíso Region) and evaluated its implementation using a mixed methods study design. The program consisted of videoconferencing mental health consultation sessions scheduled twice per month (each 90 minutes long), over a 6-month period, delivered by child and adolescent psychiatrists based in Santiago, Chile. We described the number of mental health consultation sessions, participant characteristics, perceived usefulness and acceptability, and experiences with the telepsychiatry consultation program.ResultsDuring the 6-month study period, 15 videoconferencing mental health consultation sessions were held. The telepsychiatry consultation program assisted PHC clinicians in assigning the most adequate diagnoses and making treatment decisions on pharmacotherapy and/or psychotherapy of 11 minors with complex care needs. The intervention was perceived to be useful by PHC clinicians for improving the resolution capacity in the treatments of this patient population. Limitations such as connectivity issues were resolved in most sessions.ConclusionsThe telepsychiatry consultation program was feasible and potentially useful to support PHC clinicians in the management of institutionalized children and adolescents with complex psychosocial care needs living in a poorly resourced setting. A larger scale trial should assess clinical outcomes in the patient population. Regulations and resources for this service model are needed to facilitate sustainability and large-scale implementation.     

Barriers to HIV Care: An Exploration of the Complexities That Influence Engagement in and Utilization of Treatment

This study is an exploration of engagement in outpatient medical care, medication utilization, and barriers to treatment utilization among 24 predominantly low-income, ethnic minority adults who were admitted to an urban hospital for HIV-related illnesses. A semi-structured interview was administered during the sample's hospital stay to explore patterns of service use and identify barriers to care. The majority of the sample was connected to an outpatient provider and satisfied with the care they received; however, most missed treatment appointments and skipped medication dosages. Health and treatment-related barriers, competing demands, and co-occurring mental health symptoms and illicit substance use were identified as barriers to care. Multiple obstacles indigenous to the individual, their treatment, and the environment prevented consistent treatment use among an economically disadvantaged ethnic minority sample: Implications and future directions in engaging vulnerable populations into health care for HIV are discussed.     

Barriers to HIV care: an exploration of the complexities that influence engagement in and utilization of treatment

This study is an exploration of engagement in outpatient medical care, medication utilization, and barriers to treatment utilization among 24 predominantly low-income, ethnic minority adults who were admitted to an urban hospital for HIV-related illnesses. A semi-structured interview was administered during the sample's hospital stay to explore patterns of service use and identify barriers to care. The majority of the sample was connected to an outpatient provider and satisfied with the care they received; however, most missed treatment appointments and skipped medication dosages. Health and treatment-related barriers, competing demands, and co-occurring mental health symptoms and illicit substance use were identified as barriers to care. Multiple obstacles indigenous to the individual, their treatment, and the environment prevented consistent treatment use among an economically disadvantaged ethnic minority sample: Implications and future directions in engaging vulnerable populations into health care for HIV are discussed.     

Psychiatric morbidity, service use, and need for care in the general population: results of The Netherlands Mental Health Survey and Incidence Study

OBJECTIVES: This study examined the use of primary health care, mental health care, and informal care services, as well as unmet care needs, by individuals with different psychiatric diagnoses. METHODS: Data were derived from the Netherlands Mental Health Survey and Incidence Study and were based on a representative sample (n = 7147) of the general population (aged 18-64 years). RESULTS: In a 12-month period, 33.9% of those with a psychiatric disorder used some form of care; 27.2% used primary care, and 15.3% used mental health care. Patients with mood disorders were the most likely to enlist professional care; those with alcohol- and drug-related disorders were the least likely to do so. Higher educated persons who live alone, single parents, unemployed persons, and disabled persons were more likely to use mental health care. Unmet need for professional help was reported by 16.8% (men 9.9%, women 23.9%) of those with a disorder. CONCLUSIONS: Care use varies widely by diagnostic category. The role of general medical practitioners in treating persons with psychiatric disorders is more limited than was anticipated. Patients in categories associated with extensive use of professional care are more likely to have unmet care needs.     

Mental Health Service Use Before and After Diagnosis of Early-Onset Bipolar Disorder

To investigate patterns of mental health services, psychotropic treatments, and psychiatric diagnoses received by youth diagnosed with bipolar disorder, insurance claims of 323 youth (ages 6–18 years) were examined from the 2000–2001 Thomson/Medstat-MarketScan(c) database. Longitudinal patterns are assessed 6 months prior and following a new treatment episode of bipolar disorder. Youth subgroups (i.e., continuous, intermittent, and discontinuous services), defined by persistence of claims associated with a bipolar diagnosis, are compared by demographic and clinical characteristics. Virtually all youth had high rates of mental health service use and treatment immediately following initial bipolar diagnosis, but only half continued to receive services 6 months following diagnosis. A continuous pattern of claims associated with a bipolar diagnosis was associated with using more resources, receiving initial diagnosis from a mental health professional, being in a managed care plan, and having more psychiatric diagnoses following index bipolar diagnosis. Further research should examine how continuity of claims for bipolar is related to treatment quality and clinical outcomes.     

Is the English National Health Service meeting the needs of mentally distressed Chinese women?

OBJECTIVES: To identify barriers to communication between health care workers and Chinese women living in England, a group who are known to use the National Health Service (NHS) less than other ethnic groups; to consider whether such barriers lead to inequitable access to NHS mental health treatment; and to determine the extent to which this results from institutional racism. METHOD: A purposive sample of 42 Chinese women living in South-East England aged 29-60 years derived from a primary care group, two secondary mental health service providers and three Chinese associations. Subjects had all consulted a general practitioner and had either experienced mental distress (n= 24) and/or had used traditional Chinese medicine (n = 25). RESULTS: Communication with health care professionals was hindered by a lack of common language and an absence of shared concepts concerning the causes and manifestations of health and illness, particularly mental health. This lack of communication resulted in delayed diagnoses, misunderstood treatment regimens and deterred women from (re-)presenting to the NHS. Among our informants, these types of problem were more acute for those women who were most marginalised from English-language culture. CONCLUSIONS: Linguistic and conceptual problems explain Chinese women's relatively poor access to mental health services. The continuing failure to tackle systematically these communication problems through the routine provision of interpretation and advocacy services lays the health care system open to the charge of "institutional racism".     

Differences between generalists and mental health specialists in the psychiatric treatment of Medicare beneficiaries.

OBJECTIVE: To examine differences between the general medical and mental health specialty sectors in the expenditure and treatment patterns of aged and disabled Medicare beneficiaries with a physician diagnosis of psychiatric disorder. DATA SOURCES: Based on 1991-1993 Medicare Current Beneficiary Survey data, linked to the beneficiary's claims and area-level data on provider supply from the Area Resources File and the American Psychological Association. STUDY DESIGN: Outcomes examined included the number of psychiatric services received, psychiatric and total Medicare expenditures, the type of services received, whether or not the patient was hospitalized for a psychiatric disorder, the length of the psychiatric care episode, the intensity of service use, and satisfaction with care. We compared these outcomes for beneficiaries who did and did not receive mental health specialty services during the episode, using multiple regression analyses to adjust for observable population differences. We also performed sensitivity analyses using instrumental variables techniques to reduce the potential bias arising from unmeasured differences in patient case mix across sectors. PRINCIPAL FINDINGS: Relative to beneficiaries treated only in the general medical sector, those seen by a mental health specialist had longer episodes of care, were more likely to receive services specific to psychiatry, and had greater psychiatric and total expenditures. Among the elderly persons, the higher costs were due to a combination of longer episodes and greater intensity; among the persons who were disabled, they were due primarily to longer episodes. Some evidence was also found of higher satisfaction with care among the disabled individuals treated in the specialty sector. However, evidence of differences in psychiatric hospitalization rates was weaker. CONCLUSIONS: Mental health care provided to Medicare beneficiaries in the general medical sector does not appear to substitute perfectly for care provided in the specialty sector. Our study suggests that the treatment patterns in the specialty sector may be preferred by some patients; further, earlier findings indicate geographic barriers to obtaining specialty care. Thus, the matching of service use to clinical need among this vulnerable population may be inappropriate. The need for further research on outcomes is indicated.     

Primary care satellite clinics and improved access to general and mental health services

OBJECTIVES: To evaluate the relationship between the implementation of community-based primary care clinics and improved access to general health care and/or mental health care, in both the general population and among people with disabling mental illness. STUDY SETTING: The 69 new community-based primary care clinics in underserved areas, established by the Department of Veterans Affairs (VA) between the last quarter of FY 1995 and the second quarter of FY 1998, including the 21 new clinics with a specialty mental health care component. DATA SOURCES: VA inpatient and outpatient workload files, 1990 U.S. Census data, and VA Compensation and Pension files were used to determine the proportion of all veterans, and the proportion of disabled veterans, living in each U.S. county who used VA general health care services and VA mental health services before and after these clinics began operation. DESIGN: Analysis of covariance was used to compare changes, from late FY 1995 through early FY 1998, in access to VA services in counties in which new primary care clinics were located, in counties in which clinics that included specialized mental health components were located, and for comparison, in other U.S. counties, adjusting for potentially confounding factors. KEY FINDINGS: Counties in which new clinics were located showed a significant increase from the FY 1995-FY 1998 study dates in the proportion of veterans who used general VA health care services. This increase was almost twice as large as that observed in comparison counties (4.2% vs. 2.5%: F = 12.6, df = 1,3118, p = .0004). However, the introduction of these clinics was not associated with a greater use of specialty VA mental health services in the general veteran population, or of either general health care services or mental health services among veterans who received VA compensation for psychiatric disorders. In contrast, in counties with new clinics that included a mental health component the proportion of veterans who used VA mental health services increased to almost three times the proportion in comparison counties (0.87% vs. 0.31%: F = 8.3, df = 1,3091, p = .004). CONCLUSIONS: Community-based primary care clinics can improve access to general health care services, but a specialty mental health care component appears to be needed to improve access to mental health services.     

Inequities in mental health care after health care system reform in Chile

OBJECTIVES: We compared differences in mental health needs and provision of mental health services among residents of Santiago, Chile, with private and public health insurance coverage. METHODS: We conducted a cross-sectional survey of a random sample of adults. Presence of mental disorders and use of health care services were assessed via structured interviews. Individuals were classified as having public, private, or no health insurance coverage. RESULTS: Among individuals with mental disorders, only 20% (95% confidence interval [CI]=16%, 24%) had consulted a professional about these problems. A clear mismatch was found between need and provision of services. Participants with public insurance coverage exhibited the highest prevalence of mental disorders but the lowest rates of consultation; participants with private coverage exhibited exactly the opposite pattern. After adjustment for age, income, and severity of symptoms, private insurance coverage (odds ratio [OR]=2.72; 95% CI=1.6, 4.6) and higher disability level (OR=1.27, 95% CI=1.1, 1.5) were the only factors associated with increased frequency of mental health consultation. CONCLUSIONS: The health reforms that have encouraged the growth of the private health sector in Chile also have increased risk segmentation within the health system, accentuating inequalities in health care provision.     

Barriers to meeting the mental health needs of the Chinese community.

BACKGROUND:This study aimed to identify the barriers encountered by Chinese people with mental health needs in England which hindered their obtaining appropriate help from the National Health Service (NHS). METHODS: Attenders at Chinese community centres in health authority districts with resident Chinese population in excess of 2000 were invited to fill in a 12-item Chinese Health Questionnaire (12-CHQ). Individuals who scored two or above, indicating a high probability of a mental health problem, were invited to undertake a semi-structured interview. RESULTS: A total of 401 completed the 12-CHQ. Eighty-six (21.4 per cent) screened positive and 71 (82.6 per cent) agreed to be interviewed. Although 70 (98.6 per cent) were registered with a general practitioner (GP), there were long delays before they made contact with health professionals, and the GP was the first port of call for help in only 27 (38.6 per cent) interviewees. Fifty-two (74.3 per cent) had encountered difficulties when they sought professional help. The main barriers were language, interviewees' perceptions of symptoms as somatic rather than psychiatric in origin, lack of knowledge about statutory services, and lack of access to bilingual health professionals. Doctors, particularly GPs, were pivotal in the management of their conditions. The majority were prescribed psychiatric medication with only a small number in contact with community psychiatric services. Unemployment and social exclusion were common. Stigma associated with mental illness and limited knowledge in the community were identified as the causes for the widespread discrimination experienced by the interviewees. CONCLUSION: The mental health needs of these Chinese people were not adequately met by statutory services, nor could they rely on family and friends for care and support. Training for health service staff and access to health advocates are essential to maximize the effectiveness of health professional-patient contacts. The promotion of better understanding of mental illness by the Chinese community is important, and greater flexibility within the NHS is required to ensure those professionals with bilingual skills are used to the best effect.     

Mental health service use: comparing people who served in the military or received Veterans' Affairs benefits and the general population

Objectives: To compare the lifetime prevalence of affective, anxiety and substance use disorders and the use of mental health services between people who had served in the Australian Defence Force (ADF) or received Department of Veterans' Affairs (DVA) benefits and the general population. Method: The 2007 National Survey of Mental Health and Wellbeing obtained data from a nationally representative household survey of 8,841 respondents. Results: Fewer than 20% of men who had served in the ADF reported receiving benefits from DVA. ADF men were older and more likely to report poorer health than other men. They were 50% more likely to be diagnosed with any lifetime mental disorder, any affective disorder, depression, PTSD, any substance use and alcohol disorder. Almost 90% of women who received DVA benefits had not served in the ADF. DVA women were older, and more likely to report moderate/severe psychological distress and less life satisfaction than other women. There was no evidence of greater lifetime use of mental health services by ADF men or DVA women compared to the general population. Conclusions: Health care providers should ask their patients if they have connections with the military in order to better detect and treat potential mental health problems.     

Mental Health Service Use Types Among Asian Americans with a Psychiatric Disorder: Considerations of Culture and Need

Despite levels of need that are comparable with other groups, relatively few Asian Americans receive mental health care. While studies have described the tendency for Asian Americans to delay care until mental health symptoms are severe, relatively little research has examined how the severity of symptoms impact mental health service use. This study uses publicly available data from the National Latino and Asian American Study (NLAAS) and focuses solely on Asian American respondents with a psychiatric disorder (n?=?230). Unexpectedly, few Asian Americans with a psychiatric disorder received care in a medical setting. The perception of mental health needs increased the likelihood of using mental health specialist care. Social and systemic barriers together hinder mental health service use. Implications for addressing Asian American mental health service use within a changing health care environment are discussed.     

Mental health care for irregular migrants in Europe: Barriers and how they are overcome

ABSTRACT: BACKGROUND: Irregular migrants (IMs) are exposed to a wide range of risk factors for developing mental health problems. However, little is known about whether and how they receive mental health care across European countries. The aims of this study were (1) to identify barriers to mental health care for IMs, and (2) to explore ways by which these barriers are overcome in practice. METHODS: Data from semi-structured interviews with 25 experts in the field of mental health care for IMs in the capital cities of 14 European countries were analysed using thematic analysis. RESULTS: Experts reported a range of barriers to mental health care for IMs. These include the absence of legal entitlements to health care in some countries or a lack of awareness of such entitlements, administrative obstacles, a shortage of culturally sensitive care, the complexity of the social needs of IMs, and their fear of being reported and deported. These barriers can be partly overcome by networks of committed professionals and supportive services. NGOs have become important initial points of contact for IMs, providing mental health care themselves or referring IMs to other suitable services. However, these services are often confronted with the ethical dilemma of either acting according to the legislation and institutional rules or providing care for humanitarian reasons, which involves the risk of acting illegally and providing care without authorisation. CONCLUSIONS: Even in countries where access to health care is legally possible for IMs, various other barriers remain. Some of these are common to all migrants, whilst others are specific for IMs. Attempts at improving mental health care for IMs should consider barriers beyond legal entitlement, including communicating information about entitlement to mental health care professionals and patients, providing culturally sensitive care and ensuring sufficient resources.     

Formal support, mental disorders and personal characteristics: a 25-year follow-up study of a total cohort of older people

The present study was designed to describe the pattern of long-term formal support received by people with mental disorders, and to investigate the relationship between the medical, psychological and social characteristics of the participants and types of formal support. This study is based on a cohort (n = 192) of people born in 1902 and 1903 in a community in Southern Sweden. The research participants were assessed using interviews, psychological tests and medical examinations. Information was collected about the use of primary healthcare and social services. The first assessment took place when the cohort was aged 67 years, and then on eight further occasions until they were 92. The participation rate ranged from 72% to 100%. During the observation period of 25 years, 53% of people with dementia eventually received both home help and institutional care compared to 34% of people with other psychiatric diagnoses and 12% of people with good mental health. The last group had all physical health problems and/or problems with activities of daily living. However, 35% of the dementia group, 46% with other psychiatric diagnoses and 52% of people with good mental health did not receive any formal support. Males and self-employed people were significantly less likely to use formal support. The institutionalised group reported loneliness significantly more often than the other two groups. In a logistic regression analysis, loneliness, low social class, high blood pressure and low problem-solving ability were predictors of formal support use. People with a mental disorder, including dementia, were significantly more likely to use formal support compared to people with good mental health. Social factors were the main factors predicting formal support.     

Mental disorders and medical care utilization of VA ambulatory care patients: the veterans health study

In this article, the authors examine patterns of medical services use among the Department of Veterans Affairs (VA) ambulatory care patients who screened positive for posttraumatic stress, depression, or alcohol-related disorders. On the basis of research linking mental disorders with increased use of medical services, the authors hypothesize that even after controlling for age and medical disease comorbidity, patients in VA ambulatory care who screen positive for targeted mental disorders would be more likely to use VA medical services and have higher rates of such use than those who did not screen positive. Baseline data were obtained from the Veterans Health Study, a longitudinal investigation of veterans' health. Four Boston-area VA ambulatory care facilities were used as study sites. A random sample of 2425 participants (mean age = 62) was drawn from male VA ambulatory care patients screened for eligibility during specified periods. Screening measures were Center for Epidemiological Studies-Depression Scale for depression, Posttraumatic Stress Disorder Checklist for posttraumatic stress disorder, and CAGE Questionnaire for alcohol-related disorders with endorsement of prior year consumption for alcohol-related disorders. Prior medical services use was assessed by self-report. Although unadjusted analyses of medical services use revealed clear effects of the screening presence of mental disorders on most outcomes, after adjusting for age and medical comorbidity, almost all these effects were reduced, and some previously nonsignificant results became significant. Findings suggest that healthcare policy and risk adjustment predicated upon the presumed relationship between mental disorders in the aggregate and medical services use should reconsider the important contributions of age, comorbid medical disorders, and specific mental disorder diagnoses.     

Psychiatric disorders among American Indian and white youth in Appalachia: the Great Smoky Mountains Study.

OBJECTIVES: This study examined prevalence of psychiatric disorders, social and family risk factors for disorders, and met and unmet needs for mental health care among Appalachian youth. METHODS: All 9-, 11-, and 13-year-old American Indian children in an 11-county area of the southern Appalachians were recruited, together with a representative sample of the surrounding population of White children. RESULTS: Three-month prevalences of psychiatric disorders were similar (American Indian, 16.7%; White, 19.2%). Substance use was more common in American Indian children (9.0% vs 3.8% in White children), as was comorbidity of substance use and psychiatric disorder (2.5% vs 0.9%). American Indian poverty, family adversity (e.g., parental unemployment, welfare dependency), and family deviance (parental violence, substance abuse, and crime) rates were higher, but the rate of family mental illness, excluding substance abuse, was lower. Child psychiatric disorder and mental health service use were associated with family mental illness in both ethnic groups but were associated with poverty and family deviance only in White children. Despite lower financial barriers, American Indian children used fewer mental health services. CONCLUSIONS: This study suggests that poverty and crime play different roles in different communities in the etiology of child psychiatric disorder.     

Barriers to managing mental health in Western Australia

Objective: To explore the views of community‐care and mental health workers on barriers to the management of mental health problems in rural Western Australia, and how these could be addressed. Design: Qualitative content analysis of semi‐structured interviews. Setting: Community and mental health services in Esperance. Subjects: One hundred per cent of relevant mental health workers, 86% of community health professionals and representatives from a wide range of community organisations were interviewed (n =38). Main outcome measures: The views of community‐care and mental health workers on barriers to the management of mental health, and how these could be addressed. Results: Barriers included confusion about the role of mental health services, limited after‐hours access and help for those in situational crisis, communication problems between services, differences in working practices and difficulties in dealing with the stigma of mental illness in rural communities. Suggested solutions were an expansion of counselling services and multi‐agency shared care with clinical streams for adults, those aged > 65 and children. Conclusion: This study revealed a number of barriers that are being addressed through a memorandum of understanding between services.     

Issues and outcomes in integrated treatment programs for dual disorders

In an integrated, dual disorder treatment program delivered at two sites, the authors address numerous barriers to delivering services to dually diagnosed consumers and employ a set of multidimensional indicators to assess outcome. Consumers who received services through the well-implemented, integrated services program for 12 months were functioning better in the community. There was a cost shifting from mental health to drug and alcohol services, as well as a one-third increase in the total costs of care by the end of the first year of treatment. Program implementation issues are described and the clinical management implications for more effectively serving dually diagnosed consumers through integrated treatment programs are discussed.     

Effectiveness of a specially trained pharmacist in a rural community mental health center.

Pharmacists having training in psychopharmacology and psychiatry are being specially trained to function in community mental health centers as a resource in psychopharmacology and to provide direct care to patients. Management information data over a 3-year period from eight rural mental health clinics indicate that these pharmacists can successfully maintain large numbers of stabilized psychiatric patients within their communities. The cost of a pharmacist''s services is, conservatively, one-half that of a psychiatrist''s services. A followup study of the stabilized and active aftercare outpatients in the 10-county rural area in which the 8 clinics are located revealed that those patients who received all their direct care from the pharmacist were functioning at a slightly healthier level than the other aftercare patients. The pharmacist''s patients indicated that they were at least as satisfied with their care as were the aftercare patients who received care from other mental health professionals. If the results of this study can be generalized to other community mental health centers in rural areas, a pharmacist can provide services effectively when psychiatrists are inaccessible or unavailable or when funds for mental health professionals are limited.