Use of public mental health services by Russian refugees.

OBJECTIVES: This study identifies the demographic characteristics and patterns of mental health service use among Russian refugees in New York State. METHODS: Data from a 1995 statewide survey of characteristics of patients served by the New York State mental health system were analyzed using chi square statistics and logistic regression. RESULTS: The demographic characteristics and service-use patterns of Russian refugees are different from those of non-Russian refugees and non-refugees. Russian refugees who used mental health services were likely to be older women with major depression who were enrolled in Medicaid and who were using those services for the first time. Relying heavily on themselves, family members, or friends as referral sources, they tended to use exclusively individual, outpatient services at voluntary, nonprofit agencies. CONCLUSIONS: Existing services systems must recognize the presence of Russian refugees. To improve access and service use, outreach efforts to the refugee community should be conducted, and services must be tailored to meet their mental health needs.     

Gender differences in the use of outpatient mental health services

Current economic constraints necessitate careful planning and evaluation of mental health services. Gender differences in need and use of outpatient mental health services are synthesized based on current epidemiological research. Although overall prevalence rates of mental disorder are similar, women use more outpatient mental health services than do men. This disparity exists largely within the primary care sector. The study of social roles and behavior may help explain these gender differences. Implications for planning and organizing outpatient mental health services are discussed.     

Does stigma keep poor young immigrant and U.S.-born Black and Latina women from seeking mental health care?

OBJECTIVE: This study examined the extent to which stigma-related concerns about mental health care account for the underuse of mental health services among low-income immigrant and U.S.-born black and Latina women. METHODS: Participants included 15,383 low-income women screened for depression in county entitlement services who were asked about barriers to care, stigma-related concerns, and whether they wanted or were getting mental health care. RESULTS: Among those who were depressed, compared with U.S.-born white women, each of the black groups were more likely to report stigma concerns (African immigrants, odds ratio [OR]=3.28, p=.004; Caribbean immigrants, OR=6.17, p=.005; U.S.-born blacks, OR=6.17, p=.06). Compared with U.S.-born white women, immigrant African women (OR=.18, p<.001), immigrant Caribbean women (OR=.11, p=.001), U.S.-born black women (OR=.31, p<.001), and U.S.-born Latinas (OR=.32, p=.03) were less likely to want treatment. Conversely, compared with U.S.-born white women, immigrant Latinas (OR=2.17, p=.02) were more likely to want treatment. There was a significant stigma-by-immigrant interaction predicting interest in treatment (p<.001). Stigma reduced the desire for mental health treatment for immigrant women with depression (OR=.35, p<.001) to a greater extent than it did for U.S.-born white women with depression (OR=.52, p=.24). CONCLUSIONS: Stigma-related concerns are most common among immigrant women and may partly account for underutilization of mental health care services by disadvantaged women from ethnic minority groups.     

Use of VA aftercare following military discharge among patients with serious mental disorders

OBJECTIVE: This study examined the use of Department of Veterans Affairs (VA) aftercare services among patients with serious mental disorders who were discharged from the military after a first admission to a Department of Defense (DoD) hospital. METHODS: Administrative data from the DoD and VA health systems were linked to identify active-duty servicemen and -women who were hospitalized in a military hospital with a diagnosis of major depression, bipolar disorder, or schizophrenia between 1993 and 1996 and who were subsequently discharged from the military. Split population survival analysis was used to examine separately the correlates of contact with VA outpatient mental health services and, among those who had contact, the time to contact after military discharge. RESULTS: Fifty-two percent of 2,861 identified individuals had received outpatient care from VA mental health clinics by the end of September 1998. The rate of contact was lower than in virtually all studies of aftercare following hospital discharge. Women, older persons, and persons with schizophrenia or bipolar disorder were more likely to contact VA outpatient mental health services than men, younger persons, and those with major depression. Among those who made contact, older persons had a longer time to contact. CONCLUSIONS: Many people who leave the military because of serious mental illness do not receive aftercare from the VA. The reasons for such low rates of contact are not clear. Identifying patients who need aftercare but do not receive it and ensuring that they have access to needed services remains an important challenge for the DoD and the VA.     

Use of mental health services by men injured through community violence

OBJECTIVE: The aim of this study was to assess the use of mental health services and predictors of use among men injured through community violence. METHODS: This one-year prospective study examined use of mental health services in a sample of 231 men who were injured through community violence and hospitalized at an urban trauma center. Predictors of mental health service use that were examined included age, ethnicity, income, neuroticism, injury severity, previous mental health service use, and need for services. Need for services was defined objectively by self-report of symptoms of posttraumatic stress disorder (PTSD) and subjectively by perception of an injury-related emotional problem. RESULTS: Univariate logistic regression analysis showed that older age, non-Latino ethnicity, previous use of services, and need for services predicted service use in the year after the injury. In a multivariate logistic regression analysis, objective and subjective need for services and older age predicted postinjury service use. In the subset of men who were symptomatic postinjury, only older age and objective need predicted use of mental health services. CONCLUSIONS: Despite high rates of need for services related to PTSD after violent injury in this sample, the rate of mental health service use was low. Psychoeducation about postinjury reactions and attention to structural barriers to services may help increase rates of care in this population.     

The differential effect of attitudes on the use of mental health services

Summary This study examines the relationship between attitudes and use of mental health related services using data collected from 4838 respondents in the first wave of the Yale Epidemiological Catchment Area (ECA) project. Respondents were asked about their propensity to use mental health services, their perceptions of barriers to using services, and the potential reactions of family members to their receiving mental health treatment. Each of these measures was related to use of mental health services — but only among women meeting DIS-DSM III criteria for a recent psychiatric disorder, our indicator of need for treatment. These findings suggest that increasing the availability and accessability of mental health treatment services will not promote superfluous utilization. On the other hand, such efforts may not be sufficient to reduce unmet need for mental health treatment among men with psychiatric disorders. These findings also contribute to our understanding of the disproportional use of mental health related services by women.     

Needs and Preferences for Receiving Mental Health Information in an African American Focus Group Sample

The purpose of this study is to better understand the mental health/illness information and service delivery preferences among African American residents of Baltimore. We conducted four focus groups (n = 42) among African American adults currently unconnected with the mental health system. Participants expressed fear of stigma and perceptions of racism as major barriers to seeking information and/or services and discussed some normalizing strategies to address these barriers. African Americans harbor cultural and traditional beliefs regarding mental illness which could also act as barriers. Findings have implications for imparting acceptable and culturally sensitive mental health education and service delivery programs in community settings.     

Use of mental health and substance abuse treatment services among adults with HIV in the United States

BACKGROUND: The need for mental health and substance abuse services is great among those with human immunodeficiency virus (HIV), but little information is available on services used by this population or on individual factors associated with access to care. METHODS: Data are from the HIV Cost and Services Utilization Study, a national probability survey of 2864 HIV-infected adults receiving medical care in the United States in 1996. We estimated 6-month use of services for mental health and substance abuse problems and examined socioeconomic, HIV illness, and regional factors associated with use. RESULTS: We estimated that 61.4% of 231 400 adults under care for HIV used mental health or substance abuse services: 1.8% had hospitalizations, 3.4% received residential substance abuse treatment, 26.0% made individual mental health specialty visits, 15.2% had group mental health treatment, 40.3% discussed emotional problems with medical providers, 29.6% took psychotherapeutic medications, 5.6% received outpatient substance abuse treatment, and 12.4% participated in substance abuse self-help groups. Socioeconomic factors commonly associated with poorer access to health services predicted lower likelihood of using mental health outpatient care, but greater likelihood of receiving substance abuse treatment services. Those with less severe HIV illness were less likely to access services. Persons living in the Northeast were more likely to receive services. CONCLUSIONS: The magnitude of mental health and substance abuse care provided to those with known HIV infection is substantial, and challenges to providers should be recognized. Inequalities in access to care are evident, but differ among general medical, specialty mental health, and substance abuse treatment sectors.     

Differences in Use of Government Subsidised Mental Health Services by Men and Women with Psychological Distress: A Study of 229,628 Australians Aged 45 Years and Over

This study examined factors associated with use of government subsidised mental health services by 229,628 men and women from the Sax Institute’s 45 and Up Study. Logistical regression models assessed use of mental health services by gender and according to level of psychological distress. Approximately equal proportion of men and women had high psychological distress scores (approximately 7%) but only 7% of these men and 11% of these women used services. Use was associated with predisposing (younger age and higher education), enabling (private health insurance) and need factors (higher psychological distress scores). Associations were similar for men and women except urban area of residence, separated/divorced marital status, and smoking were associated with service use for women but not men. Results suggest some inequity in the use of services by those with higher levels of need and further efforts may be required to reach people with higher need but lower service use.     

Unmet Needs for Mental Health Services for Latino Older Adults: Perspectives from Consumers, Family Members, Advocates, and Service Providers

This study qualitatively assessed the need for mental health services among Latino older adults in San Diego, California. The primary mental health issue was depression. Primary organizational barriers to accessing services were language and cultural barriers secondary to a lack of translators, dearth of information on available services, and scarcity of providers representative of the Latino community. Other challenges included a lack of transportation and housing, and the need for socialization and social support. Latino older adults experienced their unmet needs in ways associated with their cultural background and minority status. Age- and culturally-appropriate services are needed to overcome these barriers.     

Ethnic Variations in Mental Health Attitudes and Service Use Among Low-Income African American, Latina, and European American Young Women

This study examines the predictors of mentalhealth service use among patients in an ethnicallydiverse public-care women's clinic. While waiting fortheir clinic appointments, 187 Latina, African American, and White women were interviewed about theirattitudes towards mental illness and mental healthservices. White women were much more likely to have madea mental health visit in the past than the ethnic minority women. Having a substance use problem,use of mental health services by family or friends, andbeliefs about causes of mental illness were allpredictors of making a mental health visit.     

Initiation and use of public mental health services by persons with severe mental illness and limited english proficiency

OBJECTIVE: Few studies have examined the effect of limited English proficiency on use of mental health services by persons with mental illness from ethnic minority groups who are uninsured or publicly insured. This study examined how indigent or publicly insured Latino and Asian adults with limited English proficiency initially accessed the public mental health system and how their use of services changed over time compared with English-proficient peers. METHODS: Data from San Diego County for fiscal years 2000-2005 were used to examine point of first contact and use of inpatient, emergency, and outpatient services in the 18 subsequent months among 9,243 clients with a psychiatric diagnosis of schizophrenia, bipolar disorder, or major depression. Multivariate regression models were used to compute standardized estimates of utilization. RESULTS: Latino and Asian clients with limited English proficiency were significantly less likely to first access the system through emergency services and more likely to access the system through outpatient services (p<.001 for each comparison). In two outpatient programs that were focused on delivering services to clients with limited English proficiency, clients had a higher intensity of outpatient service use than clients in clinics that did not have such a focus (p<.05 for each). CONCLUSIONS: The initial pattern of service use was favorable for both groups. However, over time this pattern persisted for Asian clients with limited English proficiency but not for Latino clients with limited English proficiency. Findings suggest that ethnically focused programs may be an effective approach to engaging populations that are underrepresented in the mental health system.     

Intrinsic and extrinsic barriers to mental health care among community-dwelling younger and older adults

This study examined intrinsic and extrinsic barriers to mental health care among younger (n = 76; M age = 23 years) and older adults (n = 88; M age = 71 years) using a new 56 item self-report measure, Barriers to Mental Health Services Scale (BMHSS). The BMHSS was developed to examine 10 barriers to the utilization of mental health services: help-seeking attitudes, stigma, knowledge and fear of psychotherapy, belief about inability to find a psychotherapist, belief that depressive symptoms are normal, insurance and payment concerns, ageism, concerns about psychotherapist's qualifications, physician referral, and transportation concerns. Results indicated that younger adults perceived fear of psychotherapy, belief about inability to find a psychotherapist, and insurance concerns to be greater barriers than older adults. Men perceived stigma to be a greater barrier than women whereas women perceived finding a psychotherapist to be a greater barrier than men. The rank order of the BMHSS subscales was strongly similar for younger and older adults (r = 0.90, p = 0.000). These results also provide further evidence that stigma about receiving mental health services is not a primary barrier among younger or older adults.     

I. Comparing Use of Public and Private Mental Health Services: The Enduring Barriers of Race and Age

Data from the NIMH-Epidemiologic Catchment AreaProject were used to predict differential use of privateversus public outpatient mental health services, asalient concern in integrating public and private services in market-based health care reformefforts. Having a recent psychiatric disorder, being age25-44, female, white, of higher educational level, andunmarried increase the odds of any mental health service use. However, odds of treatment in thepublic sector are increased for males, AfricanAmericans, those with low educational and income levels,and odds are mark edly decreased for the elderly,suggesting significant barriers to care for these mentallyill subpopulations.     

Was there unmet mental health need after the September 11, 2001 terrorist attacks?

BACKGROUND: This study examined the use of professionals for mental health problems among New York City residents who were directly affected by the September 11, 2001 terrorist attacks on the World Trade Center (WTC) or had a probable diagnosis of post-traumatic stress disorder (PTSD) or depression in its aftermath. Correlates of help seeking from professionals for mental health problems after the attacks and barriers to care were also assessed. METHOD: Data were from a random digit dial telephone survey of 2,752 adults representative of the Greater New York Metropolitan area conducted 6 months after the September 11 terrorist attacks. RESULTS: Fifteen percent of those directly affected and 36% of those with probable PTSD or depression sought help from a professional for a mental health problem after the attacks. There was little new utilization of professionals for mental health problems after the attacks among persons who were not already receiving care prior to September 11. Barriers that prevented people from seeking help for mental health problems 6 months after the September 11 attacks included traditional barriers to care (e.g., cost) and barriers that are unique to the post-disaster context (e.g., the belief that others need the services more than oneself). CONCLUSIONS: This study suggests that there was potential unmet mental health need in New York City 6 months after the September 11 attacks on the WTC, but these findings should be tempered by research showing an apparent decrease in population-rates of PTSD. In the aftermath of a disaster, interventions should target persons with mental health needs who were not previously seeking help from a professional for a mental health problem.     

Race, ethnicity, and the use of services for mental disorders: results from the National Survey of American Life

CONTEXT: Little is known about differences in the unmet need for mental health service use between African Americans and Caribbean blacks. OBJECTIVE: To extend the National Survey of Black Americans by examining 12-month mental health service use for African Americans and Caribbean blacks from the recently completed National Survey of American Life. DESIGN AND SETTING: National household probability samples of noninstitutionalized African Americans and Caribbean blacks (blacks from Caribbean area countries now living in the United States) conducted between February 2001 and June 2003, using a slightly modified World Mental Health version of the World Health Organization's Composite International Diagnostic Interview. PARTICIPANTS: A total of 3570 African Americans and 1621 Caribbean blacks 18 years and older (N = 5191). MAIN OUTCOME MEASURES: Proportion of respondents with 12-month DSM-IV disorders who sought help in the specialty mental health, general medical, human service, and complementary-alternative medicine treatment sectors. The percentage receiving minimally adequate treatment was also assessed. RESULTS: Overall, 10.1% of respondents used some form of mental heath care services in the past year. Use of services was much higher among those who met criteria for a 12-month DSM-IV disorder (31.9%) than among those who did not (5.4%). Forty-nine percent of respondents with serious mental illness used services, whereas 39.3% had contact with mental health care specialists. The youngest and oldest age groups were least likely to obtain any services. Among African Americans, women were more likely than men to use general medical care and services from any sector. Respondents with the most years of education showed the highest use of services. CONCLUSIONS: The underuse of mental health services among black Americans remains a serious concern. Educational interventions that focus on both consumers and mental health care professionals are needed.     

The relationship between body mass index and mental health

BACKGROUND: The association between atypical body weight and mental health remains poorly understood. We examined the relationship between body mass index and mental health in a population-based study of adults that included the full range of body weights, three disorder types, and three levels of mental illness severity. METHODS: Data came from the 2003 Alberta Mental Health Survey (n=5383), which included a validated, standard instrument for measurement of DSM-IV mental disorders as well as several indicators of psychiatric symptoms. Associations were examined using crosstabulation and chi squared statistics, and logistic regression adjusting for sociodemographic variables. RESULTS: Findings differed by type and severity of mental illness and by sex and age. For instance, anxiety disorders were elevated among underweight men compared to normal weight men and to women. Substance use disorders were elevated among obese men at younger compared to older ages. Mood disorders were elevated among obese women compared to normal weight women, and subclinical anxiety/depression was reduced among obese men compared to normal weight men and to women. CONCLUSIONS: These analyses highlight the importance of considering type of mental illness, level of severity, sex and age when examining the relationship between BMI and mental health. The diversity of patterns observed, detectable at the population level, warrant further examination and monitoring.     

Women and outpatient mental health services: use by black, Hispanic, and white women in a national insured population

Factors affecting ethnic differences in women's use of outpatient mental health services were analyzed to determine whether lower use by black and Hispanic women occurred when socioeconomic and other factors are controlled. Employing the Andersen and Newman model of health use, insurance claims of 1.2 million federal employees insured by Blue Cross/Blue Shield in 1983 were analyzed to identify significant predictors of use. Results revealed that black and Hispanic women had lower probabilities and amounts of use when compared to white women even after controlling for a number of variables. Further research is needed to examine cultural and gender-related factors that may underlie ethnic differences; attitudinal factors and service system barriers are also implicated. Such findings have policy implications in the current climate of health care reform for which efforts are needed to increase access to care for ethnic minority women and other underserved populations.     

Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders

OBJECTIVE: This study examined the outcomes of individuals with co-occurring disorders who received drug treatment in programs that varied in their integration of mental health services. Patients treated in programs that provided more on-site mental health services and had staff with specialized training were expected to report less substance use and better psychological outcomes at follow-up. METHODS: Participants with co-occurring disorders were sampled from 11 residential drug abuse treatment programs for adults in Los Angeles County. In-depth assessments of 351 patients were conducted at treatment entry and at follow-up six months later. Surveys conducted with program administrators provided information on program characteristics. Latent variable structural equation models revealed relationships of patient characteristics and program services with drug use and psychological functioning at follow-up. RESULTS: Individuals treated in programs that provided specific dual diagnosis services subsequently had higher rates of utilizing mental health services over six months and, in turn, showed significantly greater improvements in psychological functioning (as measured by the Brief Symptom Inventory and the RAND Health Survey 36-item short form) at follow-up. More use of psychological services was also associated with less heroin use at follow-up. African Americans reported poorer levels of psychological functioning than others at both time points and were less likely to be treated in programs that provided mental health services. CONCLUSIONS: Study findings support continued efforts to provide specialized services for individuals with co-occurring disorders within substance abuse treatment programs as well as the need to address additional barriers to obtaining these services among African Americans.     

Factors associated with receiving help and risk factors for disaster-related distress among Connecticut adults 5–15 months after the September 11th terrorist incidents

Background To obtain prevalence estimates and identify factors associated with psychological problems and receipt of help by a geographically proximate population in which some persons had direct exposure but the overall prevalence of direct exposure was low, 5–15 months after the September 11th, 2001 terrorist incidents. Method Telephone survey data from the Behavioral Risk Factor Surveillance System (BRFSS) (Connecticut Module) with a randomly selected cohort of 2741 women and 1899 men aged 18 and older were examined using bivariate Chi Square and multivariate logistic regression analyses of weighted data. Results One in three respondents reported 9/11-related psychological problems, 26% of whom reported receiving formal services or peer support. Risk factors for reporting psychological problems included being surveyed earlier, female gender, age 64 or younger, Hispanic ethnicity, disability, recent depression, and reporting one day or more in the past 30 of poor mental health, sleep problems or worry. Poor mental health was associated with receipt of formal services, and increased alcohol use was associated with receipt of peer support. Conclulsion In the post-impact recovery period following mass trauma, psychological problems by persons with ongoing mental health conditions or increased alcohol use warrant continuing public and professional attention. Women, Hispanics, and disabled adults also may be under-served.