Changes in Satisfaction with Mental Health Services Among Blacks,Whites, and Hispanics in the Department of Veterans Affairs

This paper presents an analysis of changes in satisfaction of minorities with inpatient mental health services provided by the Veterans Health Administration (VHA) during a period of major system change (1995-2001). Post discharge data from 16,223 veterans who received inpatient VHA mental healthservices at 87 medical centers during this period was examined using hierarchical linear models. Blacks were found to have higher satisfaction levels on most measures over the period of study while the satisfaction of whites and Hispanics were not significantly different. There was little change over the study period in the relative satisfaction of minorities and whites. Changes in patterns of VHA mental health care have not adversely affected the satisfaction of minority veterans.     

Trends in the inpatient mental health treatment of children and adolescents in US community hospitals between 1990 and 2000

CONTEXT: Previous work has demonstrated marked changes in inpatient mental health service use by children and adolescents in the 1980s and early 1990s, but more recent, comprehensive, nationally representative data have not been reported. OBJECTIVE: To describe trends in inpatient treatment of children and adolescents with mental disorders between 1990 and 2000. DESIGN AND SETTING: Analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, a nationally representative sample of discharges from US community hospitals sponsored by the Agency for Healthcare Research and Quality. PATIENTS: Patients aged 17 years and younger discharged from US community hospitals with a principal diagnosis of a mental disorder. MAIN OUTCOME MEASURES: Changes in the number and population-based rate of discharges, total inpatient days and average length of stay, charges, diagnoses, dispositions, and patient demographic and hospital characteristics. RESULTS: Although the total number of discharges, population-based discharge rate, and daily charges did not significantly change between 1990 and 2000, the total number of inpatient days and mean charges per visit each fell by approximately one half. Median length of stay declined 63% over the decade from 12.2 days to 4.5 days. Declines in median and mean lengths of stay were observed for most diagnostic categories and remained significant after controlling for changes in background patient and hospital characteristics. Discharge rates for psychotic and mood disorders as well as intentional self-injuries increased while rates for adjustment disorders fell. Discharges to short-term, nursing, and other inpatient facilities declined. CONCLUSIONS: The period between 1990 and 2000 was characterized by a transformation in the length of inpatient mental health treatment for young people. Community hospitals evaluated, treated, and discharged mentally ill children and adolescents far more quickly than 10 years earlier despite higher apparent rates of serious illness and self-harm and fewer transfers to intermediate and inpatient care.     

A Model of Patients' Satisfaction with Treatment for Posttraumatic Stress Disorder

There is little empirical knowledge about the contribution of treatment effectiveness to patient satisfaction, particularly in the area of mental health. We conducted this study to assess the satisfaction of 3,646 veterans who received treatment from March 1996–April 1997 at specialized inpatient and residential posttraumatic stress disorder programs at Departments of Veterans Affairs in 35 locations. We used structural equation modeling to evaluate and extend a model of connections among pretreatment characteristics, treatment structure, treatment effectiveness and patient satisfaction. The results suggest three implications for mental health administration and program planning: (1) any valid comparison of programs requires that differences in patient characteristics be taken into account, (2) satisfaction and effectiveness are largely separate indices of quality, and (3) shortening the length of stay to contain cost is likely to lower patient satisfaction.     

The Quality of VA Mental Health Services

This study examines whether male and female veterans differ on either subjective or objective measures of the quality of VA mental health care. The study sample were all discharged with a psychiatric diagnosis from a VA inpatient mental health program. Results indicate that women were less satisfied with inpatient care, but were mixed on their satisfaction with overall mental health care. Males and females did not differ on the quality of inpatient care, but women had significantly higher quality of outpatient care. These results not only highlight the need to stratify or adjust quality measures by gender, but also highlight the potential confounding effect of sub-group specific health behaviors on measures of quality.     

Mental illness as a predictor of satisfaction with inpatient care at Veterans Affairs hospitals.

OBJECTIVE: Patient satisfaction ratings are increasingly being used as an indicator of quality of care. However, satisfaction scores do not account for differences in satisfaction among patients that may be attributable to sociodemographic characteristics or type of illness rather than to the quality of service delivery. This study examines the role of psychiatric diagnosis in satisfaction with inpatient care delivered at Department of Veterans Affairs (VA) hospitals. METHODS: Data were taken from a large national VA customer feedback survey of patients discharged from VA hospitals between June 1 and August 31, 1995 (N=38,789). Analyses examined whether patients discharged with a psychiatric diagnosis were less satisfied with care than those discharged with a nonpsychiatric diagnosis. RESULTS: Patients with a psychiatric diagnosis were less satisfied with their care, regardless of whether they were treated in a psychiatric treatment program or a medical unit, and this relationship remained after the analysis adjusted for other determinants of satisfaction. The association between low satisfaction and psychiatric diagnosis was more pronounced among nonblack patients. CONCLUSIONS: The results suggest the need for caution in using patient satisfaction measures to compare mental health programs and other health care programs.     

Care of persons with schizophrenia: a statistical profile

This article presents the latest information available from the National Reporting Program for Mental Health Statistics on the distribution and characteristics of persons with schizophrenia served by organized, specialty inpatient, outpatient, and partial care mental health programs. Results are presented separately for persons under care at one point in time and for persons admitted over a 1-year period, in order to examine the potential for change in each type of care. Findings show that about 900,000 persons with schizophrenia were served in 1986; that inpatient and outpatient programs were relatively equivalent in total numbers served, but that considerably more patient turnover occurred in inpatient programs; and that partial care programs, although small, were evolving as a locus of care for persons with schizophrenia. Some variations were observed among the different types of organizations offering each type of care, and characteristics of clients/patients that could lead to changes in each type of care were evident. Overall, the findings present a useful composite picture of specialty mental health care for persons with schizophrenia. The need for longitudinal, prospective research is noted.     

Racial Comparison of Therapeutic Support, Service Use, and Satisfaction Among Male Outpatients with Severe Mental Illness

This study examined racial differences among male outpatients with severe mental illness on therapeutic support, mental health service utilization, and service satisfaction. A total of 530 participants (289 White, 179 Black, and 62 of another race) across three large mental health centers (two state funded and one federally funded) in Connecticut were examined cross-sectionally. No racial differences were found in therapeutic support, and there were essentially no racial differences in service satisfaction. Black clients reported greater use of substance abuse inpatient services than White clients and clients of other racial minorities reported greater use of mental health inpatient services than White clients, but differences were small. These findings suggest there are few racial differences in the reported quality of mental health care and service utilization among male outpatients with severe mental illness. More research is needed on where and under what circumstances health disparities exist.     

A Mental Health Program Report Card: A Multidimensional Approach to Performance Monitoring in Public Sector Programs

This report presents a comprehensive,multi-dimensional mental health program performancemonitoring system that has recently been implemented inthe Department of Veterans Affairs. Principlesunderlying the development of the system are reviewed and68 specific monitors are described addressing four majorperformance domains: access, inpatient care, outpatientcare, and economic performance. Simple methods are presented for identifying outliers, forgenerating summary performance scores across series' ofrelated monitors, and for adjusting results fordifferences in patient characteristics across locales. Although still technically imperfect, andtherefore requiring continuous improvement, monitoringsystems such as the one presented can be useful toolsguiding and improving service delivery and mental health system performance, and providing a medium ofaccountability to consumers and otherstakeholders.     

Effect of Antidepressant Choice on the Incidence and Economic Intensity of Hospitalization Among Depressed Individuals

This study identified differences in hospital utilization for mental health problems among depressed patients initially treated with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs). A retrospective sample of 2,557 patients was obtained from a private insurance claims database. Quasi-experimental, two-stage multivariate regression modeling was used to estimate the likelihood of hospitalization and subsequent inpatient expenditures. Only 2% of the sample were hospitalized, and the average expenditures per admitted patient was about $8,000. Patients initially prescribed sertraline had the same likelihood of hospitalization for a mental health problem as patients prescribed TCAs. Patients initially prescribed fluoxetine were half as likely to be hospitalized as patients initially prescribed TCAs. Once hospitalized, no differential effects of a specific antidepressant on inpatient expenditures were found.     

The volume-quality relationship of mental health care: does practice make perfect?

OBJECTIVE: An extensive literature has demonstrated a relationship between hospital volume and outcomes for surgical care and other medical procedures. The authors examined whether an analogous association exists between the volume of mental health delivery and the quality of mental health care. METHOD: The study used data for the 384 health maintenance organizations participating in the Health Employer Data and Information Set (HEDIS), covering 73 million enrollees nationwide. Analyses examined the association between three measures of mental health volume (total annual ambulatory visits, inpatient discharges, and inpatient days) and the five HEDIS measures of mental health performance (two measures of follow-up after psychiatric hospitalization and three measures of outpatient antidepressant management), with adjustment for plan and enrollee characteristics. RESULTS: Plans in the lowest quartile of outpatient and inpatient mental health volume had an 8.45 (95% CI [confidence interval]=4.97-14.37) to 21.09 (95% CI=11.32-39.28) times increase in odds of poor 7- and 30-day follow-up after discharge from inpatient psychiatric hospitalization. Low-volume plans had a 3.49 (95% CI=2.15-5.67) to 5.42 (95% CI=3.21-9.15) times increase in odds of poor performance on the acute, continuation, and provider measures of antidepressant treatment. CONCLUSIONS: The large and consistent association between mental health volume and performance suggests parallels with the medical and surgical literature. As with that previous literature, further work is needed to better understand the mechanisms underlying this association and the potential implications for using volume as a criterion in plan choice.     

Mental Health Problems and Satisfaction with Amount of State Compensation for Intentional Violent Crime Victimization in The Netherlands

The current study explored whether self-reported mental health problems among victims of violent crime (n = 151) affect their ratings of satisfaction with amount of financial compensation awarded by the Dutch state and vice versa. This topic is important to address, because satisfaction is often used as an indicator of quality of victim services. Relying on medical literature about satisfaction with compensation in patient populations, it was expected that satisfaction levels would be negatively associated with mental health problems. Mental health problems were assessed with the General Health Questionnaire. A threshold of 11/12 on this scale was used to differentiate between victims with and without probable mental health problems. In line with expectations, victims with probable mental health problems reported significantly lower levels of satisfaction than those without. Results remained unchanged after adjusting for potential confounding. Findings were discussed in light of study limitations and directions for future research.     

Clinical outcomes of a specialised inpatient unit for adults with mild to severe intellectual disability and mental illness

Background   Limitations of general psychiatric services have led to the development of specialised psychiatric programmes for patients with intellectual disability (ID) and mental health needs. Few studies have examined treatment outcomes of specialised inpatient units, and no studies have explored how the effects of intervention may differ for individuals at varying levels of cognitive ability. The present study examined clinical outcomes of inpatients with mild ID in contrast to inpatients with moderate to severe ID within the same service.
Method   Thirty-three patients (17 with mild ID and 16 with moderate to severe ID) discharged between 2006 and 2008 from a specialised inpatient unit in Canada for adults with ID and mental illness were studied. In addition to examining change in scores on clinical measures, outcomes with regard to length of stay, diagnostic change, residential change and re-admission to hospital were explored.
Results   Both groups demonstrated clinical improvement from admission to discharge. However, only patients with mild ID demonstrated improvements on the Global Assessment of Functioning.
Conclusions   This study is one of the first to consider outcomes of higher and lower functioning individuals with ID on a specialised inpatient unit. Results suggest that outcomes may be different for these groups, and some clinical measures may be more sensitive to changes in patients with more severe disabilities.     

Quality of housing among patients of an area mental health service

OBJECTIVES: The aims of the present study were to (i) assess the quality of housing for patients receiving treatment from an area mental health service; (ii) compare estimates of quality of housing using two different methods: housing type versus housing characteristics; (iii) determine whether either method for assessing quality is more useful that a combination; and (iv) examine the relationship between housing quality and case manager's assessment of the impact of the housing on the patient's mental disorder. METHODS: A survey was developed that included the demographics of the patient; housing type; living arrangements; housing characteristics as assessed by the patient's case manager; and an overall assessment by the case manager of the impact that the housing has on the patient's mental disorder. Case managers were asked to complete the housing survey on all patients they saw in the community during a 2 week period in 2003. The social worker for the inpatient unit completed the survey for all patients admitted to the inpatient unit over a 3 month period. RESULTS: Surveys were completed for a total of 362 patients. Just under 10% of patients were identified as homeless in that the person either had no housing or was living in a shelter or accommodation frequently associated with homeless persons. Almost half of the patients in the sample had housing that was either not affordable, not secure, not safe or not appropriate to their needs, that is, their housing met at least one of a range of criteria defining poor-quality housing. Sixty-one patients (16.9%) had housing that was considered by their case managers to have a substantial negative impact on their mental illness. CONCLUSIONS: Almost half of the patients treated by an area mental health service appeared to have poor-quality housing. Housing characteristics identified a higher proportion of people with poor-quality housing than did housing type. Case managers' assessments generally failed to identify a potential negative impact of poor quality housing on the person's mental disorder.     

Binge Eating in Males: A Sample Description and Treatment Outcome Study

An outcome study on inpatient treatment for binge-eating males was conducted (N = 50, average follow-up duration = 23 months). The sample differed from those described in studies of bulimia in males in that the majority of these subjects had no history of self-induced vomiting or use of laxatives or diuretics and were older and obese upon presentation for treatment. Follow-up measures indicated that these subjects responded well to inpatient treatment. Upon follow-up, subjects reported little medical or psychiatric resource utilization other than what was prescribed as aftercare, improvement in eating disorder-related medical conditions, good ratings of general mental health, and significant decreases in binge eating and other eating disorder-related behaviors over the follow-up duration. “Good” outcome patients, that is, subjects reporting substantial positive change in eating behavior     

Trends in psychiatric hospitalisation of people with schizophrenia: a register-based investigation over the last three decades

The number of psychiatric beds has declined considerably in many countries over the past decades. Long-term studies on the impact of these health care changes for the severely mentally ill, however, are still scarce. This epidemiological study investigates the use of inpatient psychiatric services by people with schizophrenia, compared to that by people with other mental disorders. We used psychiatric register data of the Swiss canton Zurich to establish the annual treatment prevalence in the period 1977-2004. For patients with psychoses, the length of inpatient episodes decreased by half. The annual number of inpatient admissions doubled. The proportion of schizophrenia patients, which accounted for 36%-41% of all inpatient treatments up to 1993, dropped to 20% in 2004, while that of other psychoses remained about the same (8%-10%) throughout the study period. This contrasts with a 2-3 fold increase in other patient groups. The annual treatment prevalence for people with schizophrenia declined from 7.3 to 2.2 per 10000 population since the 1990s and affected patients of all ages and of both sexes equally. The treatment prevalence for other psychoses remained virtually unchanged (1.3 per 10000). For all other mental disorders, there was an up to twofold increase. The study suggests that the downsizing of psychiatric hospitals has resulted in a far-reaching redistribution of overall inpatient treatment resources. The considerable decrease in inpatient treatment for people with schizophrenia emphasizes the need to further investigate the current state of coverage for and the appropriateness of health care available to this patient group.     

Integration of mental health resources in a primary care setting leads to increased provider satisfaction and patient access

Objective

This evaluation assessed the opinions and experiences of primary care providers and their support staff before and after implementation of expanded on-site mental health services and related system changes in a primary care clinic.

Method

Individual semistructured interviews, which contained a combination of open-ended questions and rating scales, were used to elicit opinions about mental health services before on-site system and resource changes occurred and repeated following changes that were intended to improve access to on-site mental health care.

Results

In the first set of interviews, prior to expanding mental health services, primary care providers and support staff were generally dissatisfied with the availability and scheduling of on-site mental health care. Patients were often referred outside the primary care clinic for mental health treatment, to the detriment of communication and coordinated care. Follow-up interviews conducted after expansion of mental health services, scheduling refinements and other system changes revealed improved provider satisfaction in treatment access and coordination of care. Providers appreciated immediate and on-site social worker availability to triage mental health needs and help access care, and on-site treatment was viewed as important for remaining informed about patient care the primary care providers are not delivering directly.

Conclusions

Expanding integrated mental health services resulted in increased staff and provider satisfaction. Our evaluation identified key components of satisfaction, including on-site collaboration and assistance triaging patient needs. The sustainability of integrated models of care requires additional study.     

Job satisfaction among mental health professionals in Rome,Italy

Although various surveys on job satisfaction have been performed in mental health care settings, no studies have investigated in-depth the level of satisfaction with the various aspects of work in Italian mental health services. In the present study, all clinical mental health staff working in a large psychiatric catchment area in Rome were invited to anonymously complete a previously validated questionnaire designed to measure job satisfaction among mental health professionals. Of the total 236 health professionals, 196 (83%) agreed to participate. Most participants were not completely satisfied with many aspects of their job, and many were not even moderately satisfied. The level of satisfaction increased with age, and it was significantly lower among hospital-ward staff compared to the staff of outpatient clinics or residential facilities, even after adjusting for age, gender, profession, work setting, and time in current job, using a multiple logistic regression model. Our findings suggest that interventions aimed at increasing job satisfaction among Italian mental health professionals might be warranted, particularly among hospital-ward staff.     

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.     

An overview of patient satisfaction with psychiatric treatment

Patient satisfaction with psychiatric treatment can strongly influence pursuit and use of mental health services as well as treatment compliance and treatment outcome. Although assessment of patient satisfaction is crucial to designing effective mental health programs, no standard methodology exists to measure satisfaction; thus it is difficult to compare findings from different satisfaction studies. The author examines the studies in four areas of satisfaction research: patient satisfaction with treatment, with participation in research, with participation as subjects in psychiatric teaching, and with involuntary commitment. He notes the variance between mental health professionals' expectations of patient satisfaction and the higher satisfaction that patients themselves report. He also discusses the need for more study of the subjective experience of patients who participate in research projects, teaching conferences, and observed psychotherapy and who undergo involuntary commitment.     

Relationship of youth satisfaction with mental health services and changes in symptoms and functioning

This study examined how youth-reported satisfaction with specialty mental health services was associated with youths' symptom and functioning change. Change in clinical functioning was assessed prospectively on the basis of parent, youth, and interviewer report for 369 youths (aged nine to 18 years at study entry) receiving mental health services. Satisfaction was assessed at two-year follow-up. The results indicated that satisfaction was only minimally associated with clinical change, and only in the case of youth-reported clinical change. Parent- and interviewer-reported change were not associated with consumer satisfaction. These results suggest that consumer satisfaction is not a good indicator of effectiveness of treatment in changing clinical functioning.