Needs for services reported by adults with severe mental illness and HIV

This study examined the needs of people with severe mental illness and HIV. Results were based on interviews and CD4 counts of 294 individuals who received services from the Los Angeles County or the New York City public mental health system. Common unmet needs included financial assistance, housing, and mental health care. Thirty percent of the participants reported that they had at least one basic need that was not being met. Unmet need was less common as HIV infection advanced and was similar in frequency to that found in the general population with HIV. People with severe mental illness and HIV may be benefiting from the special resources that are available for people with HIV.     

Utilization of health and mental health services by Los Angeles Mexican Americans and non-Hispanic whites

Utilization of general medical and mental health services by respondents in the Los Angeles Epidemiologic Catchment Area (ECA) site was compared with that in three ECA sites studied previously (New Haven, Conn, Baltimore, and St Louis). Within the Los Angeles sample, Mexican-American patterns of utilization were compared with those for non-Hispanic whites. Los Angeles respondents were less likely than those at other ECA sites to make ambulatory health care visits and to be hospitalized for physical or mental health reasons. Mexican Americans were less likely than non-Hispanic whites to report ambulatory health care but were as likely to have been hospitalized. Six percent of Los Angeles respondents reported a recent mental-health-care visit as compared with 6% to 7% of respondents at the other ECA sites. However, among respondents with Diagnostic Interview Schedule DSM-III disorders diagnosed within the six months prior to the interview, a lower proportion made a mental health visit in Los Angeles (14%) compared with the other sites (16% to 20%). Of those who made a mental-health-care visit, Los Angeles respondents with a recently diagnosed disorder were more likely than comparable respondents at the other ECA sites to visit a mental health specialist rather than a general medical care provider. Mexican Americans with a recently diagnosed mental disorder were only half as likely as non-Hispanic whites (11% vs 22%, respectively) to have made a mental health visit. However, when Mexican Americans with Diagnostic Interview Schedule/DSM-III did make a mental health visit, they were as likely as non-Hispanic whites to see a mental health specialist.     

The Feasibility of Computerized Patient Self-assessment at Mental Health Clinics

OBJECTIVES: Improving the quality of care for severe mental illness (SMI) has been difficult because patients' clinical information is not readily available. Audio computer-assisted self-interviewing (ACASI) supports data collection by asking patients waiting for appointments clinical questions visually and aurally. It has improved outcomes for many disorders. While reliable and accurate for SMI in research settings, this study assesses questions about ACASI's feasibility in usual care. DESIGN: Patient and provider surveys and provider focus groups after 12 months of ACASI implementation. SETTING: Two outpatient mental health clinics in Los Angeles, one run by the Department of Veterans Affairs and the other by Los Angeles County Department of Mental Health. PARTICIPANTS: 266 patients with SMI and 14 psychiatrists. INTERVENTION: Patients completed an ACASI survey on symptoms, drug use, medication adherence and side-effects by internet using a touch-screen monitor. A 1-page report summarizing each patient's results was printed and given to providers by patients during appointments. MAIN OUTCOME MEASURE: Feedback surveys (patients and psychiatrists) and focus groups and interviews (psychiatrists) assessed usability, usefulness, effects on treatment, and barriers to sustaining ACASI. RESULTS: Patients believed the PAS was enjoyable, easy to learn and use, and that it improved communication with their psychiatrists. Providers believed the PAS was easy to use, had a small impact on care, could be improved by being more detailed and comprehensive, and requires outside support to continue its use. CONCLUSIONS: ACASI was easy to use and enhanced communication. Systems like this can be a valuable part of quality improvement projects.     

Public-academic partnerships: using Medicaid claims data to identify service gaps for high-need clients: the NYC Mental Health Care Monitoring Initiative

Public mental health authorities have access to large administrative databases. Advances in information technology now make it possible to use secondary analyses of these data to inform policy and clinical interventions. New York City and State mental health authorities developed an initiative using Medicaid claims and other administrative data to identify individuals with serious mental illness living in New York City (NYC) who are at risk of lapses in care. The NYC Mental Health Care Monitoring Initiative represents one of the first efforts to create "evidence-based policy." The authors describe the initiative's background, development, and key collaborations.     

Community determinants of Latinos' use of mental health services

OBJECTIVE: This study examined the role of community in understanding Latino adults' (18-64 years of age) use of community mental health services. METHODS: Service utilization data from the Los Angeles County Department of Mental Health were analyzed from 2003 in two service provider areas. Demographic data, including foreign-born status, language, education, and income for the Latino population, were obtained from the 2000 U.S. Census. The study sample consisted of 4,133 consumers of mental health services in 413 census tracts from an established immigrant community and 4,156 consumers of mental health services in 204 census tracts from a recent immigrant community. Negative binomial regression analyses were conducted to examine associations between locales, community characteristics, and use of services. RESULTS: Community of residence and foreign-born status were significantly associated with Latinos' service use. Latinos from the established immigrant community were more likely to use services than Latinos from the recent immigrant community. Across both communities, census tracts with a higher percentage of foreign-born noncitizen residents showed lower service use. Within the established immigrant community, as income levels increased there was little change in utilization. In contrast, in the recent immigrant community, as income levels increased utilization rates increased as well (beta=.001, p<.001). CONCLUSIONS: The findings point out the importance of locale and community determinants in understanding Latinos' use of public mental health services.     

Reliability of self-reports about sexual risk behavior for HIV among homeless men with severe mental illness

The reliability of self-reports of sexual behaviors related to HIV transmission was examined in a study of homeless men with severe mental illness. Thirty-nine patients of a New York City shelter psychiatric program were interviewed about their sexual behaviors in the past six months. The same interview was administered twice, with a one- to two-week interval between interviews. Test-retest reliability was assessed using kappa and intraclass correlation coefficients. Reliability estimates ranged from.49 to.93 for overall sexual activity, number of partners, and specific behaviors other than receptive anal sex. Reliability was lower for condom use. The authors conclude that reliable self-reports about sexual behavior can be obtained from homeless men with severe mental illness.     

Providing Mental Health Services in the Primary Care Setting: the Experiences and Perceptions of General Practitioners at a New York City Clinic

Mental illness is a significant cause of disability worldwide, including here in the United States. Given the shortage of trained mental health professionals, a significant portion of patients needing care are managed in the primary care setting. Accountable Care Organizations (ACOs), for example, are seeking to improve the quality of care for this vulnerable population, but many are facing significant challenges relating to integration of new services. We sought to elucidate barriers faced by primary care practitioners (PCPs)—physicians, physician trainees and nurse practitioners—at a New York primary care clinic, which impede delivery of optimal care to those suffering from mental illness. The study was conducted with 32 PCPs in 2016–2017 at Mount Sinai Internal Medicine Associates in New York City. For the quantitative component of the study, a 54-item questionnaire was devised to assess their attitude, behavior and confidence in managing psychiatric patients. For the qualitative component, data was obtained from 3 open-ended questions. Responses were coded for salient themes. Analysis revealed a range of difficulties faced by PCPs. Overall, participants felt that the need to integrate mental health care into primary care was important, however they reported significant barriers in terms of lack of time, lack of resources, low confidence in treating more complex mental health conditions and difficulties with referring patient to mental health specialists. Despite a growing body of evidence that integration of mental health services in primary care leads to improved outcomes, addressing barriers to care will be key to ensuring feasibility of integration measures.     

The role of psychiatrists in primary care of patients with severe mental illness

OBJECTIVE: This study sought to identify health conditions for which a primary care psychiatrist would be an appropriate treatment provider in an integrated model of health care delivery for persons with serious mental illness. A primary care psychiatrist is a psychiatrist with primary care training who is supervised by an on-site internist. METHODS: Rating methods for health conditions were adapted from those jointly developed by Rand and the University of California, Los Angeles. A consensus panel of 14 hospital administrators, internists, psychiatrists, and nursing service representatives from three southern California Veterans Affairs health care systems was convened. Eleven physician-panelists, including five psychiatrist, five internists, and a medical specialist, rated whether a general psychiatrist, a primary care psychiatrist, an internist, or a medical specialist could reasonably provide evaluation, treatment, or preventive care for uncomplicated instances of each of 344 physical health conditions or procedures. RESULTS: A primary care psychiatrist, with supervision by an internist, was rated as an appropriate treatment provider for most of the 344 conditions. The conditions included many of those cited by patients as the most common reasons for ambulatory care visits. Panelists identified some intrusive elements of primary care, such as a pelvic examination, as potentially injurious to the psychiatrist-patient relationship and inappropriate for performance by psychiatrists. CONCLUSIONS: This study took the first essential step in evaluating the integration of primary care into the psychiatric setting. Further research is needed to determine whether use of primary care psychiatrists will increase access to primary care by persons with serious mental illness and improve outcomes.     

Access to and satisfaction with care comparing patients with and without serious mental illness

OBJECTIVES: We compared perceived access to and satisfaction with health care between patients diagnosed with serious mental illness (SMI: schizophrenia or bipolar disorder) and among those with no SMI diagnosis. METHOD: We conducted a national, cross-sectional study of VA patients in Fiscal Year (FY) 1999 (N = 7,187) who completed the VA's Large Health Survey of Veteran Enrollees (LHSV) section on access and satisfaction and either received a diagnosis of schizophrenia or bipolar disorder, or did not and were randomly selected from the general non-SMI VA patient population (non-SMI group). We compared the probability of perceived poor access and dissatisfaction using multivariable logistic regression adjusting for patient covariates. RESULTS: Compared to non-SMI patients, patients diagnosed with bipolar disorder were more likely to report difficulty in receiving care they needed (adjusted OR = 1.36,p < .05) or seeing a specialist (adjusted OR = 1.44, p < .001). Patients diagnosed with schizophrenia were more likely to report dissatisfaction, including thoroughness by their provider (adjusted OR = 1.37, p < .001) and the provider's explanation of problems (adjusted OR = 1.54, p < .001) compared to non-SMI patients. CONCLUSIONS: Patients diagnosed with bipolar disorder reported greater problems with access to health care, while those diagnosed with schizophrenia were less satisfied with the process of care.     

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.     

Access to health care in the United States: barriers for neurologic patients, challenges for neurologic physicians

Approximately 34 million people in the United States have no health insurance. Up to 80 million people have insurance inadequate to provide care for severe or long-term illness (the underinsured). In 1986, an estimated 1 million persons in the US could not obtain needed health care for financial reasons, and another 18.8 million had difficulty obtaining care. There probably are 3.2 million people with neurologic disorders among the 34 million uninsured, and more among the underinsured. Those patients probably have difficulty obtaining health care, including neurologic consultations, laboratory tests, and radiologic procedures. Congress and many state legislatures are considering various proposals to address the problems of the un- and underinsured. Several national medical professional societies have developed programs to improve access to care for their patients. The American Academy of Neurology Task Force on Access to Health Care is studying access to care for neurologic patients and will recommend a course of action to the Academy. The Task Force welcomes suggestions concerning appropriate steps to improve access to health care for patients with neurologic disorders.     

Quality of care for primary care patients with anxiety disorders

OBJECTIVE: This study evaluated quality of care for primary care patients with anxiety disorders in university-affiliated outpatient clinics in Los Angeles, San Diego, and Seattle. METHOD: Three hundred sixty-six primary care outpatients who were diagnosed with panic disorder, generalized anxiety disorder, social phobia, and/or posttraumatic stress disorder (with or without major depression) were surveyed about care received in the prior 3 months. Quality indicators were mental health referral, anxiety counseling, and use of appropriate antianxiety medication during the previous 3 months. RESULTS: Approximately one-third of patients with anxiety disorders had received counseling from their primary care provider in the prior 3 months. Fewer than 10% had receiving counseling from a mental health professional that included multiple elements of cognitive behavior therapy. Approximately 40% had received appropriate antianxiety medications in the previous 3 months, although only 25% had received them at a minimally adequate dose and duration. Overall, fewer than one in three patients had received either psychotherapy or pharmacotherapy that met a criterion for quality care. In multivariate analyses, patients with comorbid depression and/or medical illness were more likely-and patients from ethnic minorities were less likely-to receive appropriate antianxiety medications. CONCLUSIONS: Rates of quality care for anxiety disorders are moderate to low in university-affiliated primary care practices. Although an appropriate type of pharmacotherapy was frequently used, it was often of inadequate duration. Cognitive behavior therapy was markedly underused. These findings emphasize the need for practice guidelines and implementation of quality improvement programs for anxiety disorders in primary care.     

State of Spirituality-Infused Mental Health Services in Los Angeles County Wellness and Client-Run Centers

Spiritual coping is associated with positive mental health outcomes for individuals with serious mental illness, yet spirituality-infused services are seldom offered in public sector mental health agencies. The Los Angeles County Department of Mental Health introduced a policy addressing spirituality in 2012. This study explored the breadth and degree to which spirituality-infused activities were being offered in 53 Los Angeles wellness and recovery centers after the policy was widely disseminated. More than 98 % of the centers offered options for spirituality-infused activities; one-third offered spirituality-focused groups. Los Angeles’s progress may guide implementation of spirituality-infused services in other state or local public mental health systems.     

Shared decision-making preferences of people with severe mental illness

OBJECTIVE: Perceived roles and preferences were explored for shared decision making among persons with severe mental illnesses. METHODS: In this pilot study, 30 adult clients with severe mental illness in a community mental health center were surveyed about decision making regarding psychiatric medications, rehabilitation, and general medical care. RESULTS: Clients generally expressed a desire for greater participation in decisions about psychiatric care than they currently experienced. Regarding use of new psychiatric medications, 23 persons (77%) preferred autonomous or shared roles, but only 11 (37%) rated their current roles as more than passive (z=-2.83, p=.005). Clients were less likely to prefer a passive role in medication decisions about psychiatric care than about general medical care (seven persons, or 23%, versus 23 persons, or 77%; z=-3.01, p=.003). CONCLUSIONS: Most clients with severe mental illnesses prefer shared decision making, particularly in relation to their mental health care.     

Medication patterns for attention-deficit/hyperactivity disorder and comorbid psychiatric conditions in a low-income population

The aims of this study were two-fold: (1) to describe the patterns of comorbid psychiatric diagnosis and psychotropic drug therapy for children enrolled in a Medicaid-managed care program and diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2000 and (2) to examine child and provider characteristics associated with psychotropic medication patterns for this population. Multivariate logistic regression models were used to examine correlates of stimulant and seven nonstimulant psychotropic medication classes (alpha-agonists, mood stabilizer/anticonvulsant, antianxiety, standard antipsychotic, atypical antipsychotic, and tricyclic antidepressant (TCA)/other antidepressant and selective serotonin reuptake inhibitor (SSRI) antidepressant). With the exception of conduct disorders (odds ratio, 1.22; 95% confidence interval, 1.06-1.40), comorbid disorders had a significant protective effect (odds ratio less than 1) on dispensing stimulants. After adjusting for covariates, stimulant dispensing was strongly correlated with the interactions of geographic region with race/ethnicity and provider type. Children residing in the upstate New York region had an approximately ten-fold greater chance of being dispensed a stimulant compared to similar children in New York City. Utilizing a mental health provider increased the chance of being dispensed a stimulant by factor of two for children from New York City of any race/ethnicity group. Models predicting nonstimulant drug dispensing were distinct from the stimulant model. After adjusting for covariates, nonstimulant psychotropic medication dispensing was correlated with clinical factors, including comorbid disorder category and use of a mental health provider, as well as notable sociodemographic factors. Complex psychotropic medication and comorbid psychiatric disorder patterns were evident for this low-income population of children with ADHD. The roles of clinical, patient, and provider factors need to be better understood to explain these patterns of stimulant and nonstimulant psychotropic medications dispensed.     

Understanding associations between serious mental illness and HIV among patients in the VA Health System

OBJECTIVE: This study compared the recorded prevalence of HIV among veterans with and without serious mental illness. METHODS: This cross-sectional study examined data from a national sample of veterans who received a diagnosis of serious mental illness (schizophrenia, bipolar disorder, and other, nonorganic psychoses) in fiscal year 2002 (FY2002) (N=191,625) and from a national random sample of veterans in FY2002 who did not receive serious mental illness diagnoses (N=67,965). Logistic regression was used to evaluate the recorded prevalence and predictors of HIV. RESULTS: HIV diagnoses were recorded for 1.0% of patients with serious mental illness and .5% of patients without serious mental illness. Multivariate analyses indicated that individuals with bipolar disorder were no more likely than those without serious mental illness to have a recorded HIV diagnosis (OR=1.08, CI=.93-1.24), whereas those with other psychoses were more likely to have one (OR=1.18, CI=1.01-1.38). An interaction was observed between schizophrenia and substance use disorder. Compared with patients who had neither schizophrenia nor a substance use disorder, those with schizophrenia without a substance use disorder were less likely to have a recorded HIV diagnosis (OR=.49, CI=.42-.58), whereas those with a substance use disorder were more likely to have a recorded HIV diagnosis (OR=1.22, CI=1.04-1.43). CONCLUSIONS: Despite the elevated crude recorded prevalence of HIV, multivariate analyses suggested that HIV-related risk factors underlie the associations between HIV and the serious mental illness diagnoses. For patients with schizophrenia, this study is the first to demonstrate reduced HIV risk in the absence of a substance use disorder.     

Health care utilization by persons with severe and persistent mental illness

Claims for physical health care among 220 Medicaid enrollees with severe mental illness and 166 Medicaid enrollees who were not enrolled in the public mental health system were compared. Claims for the mentally ill group were 18 percent less than for the group without severe mental illness. Twenty-eight percent of claims for mentally ill patients were for treatment in emergency rooms and ambulances, compared with 11 percent for patients without mental illness; 26 percent of claims for patients without mental illness were for care in outpatient surgical and outpatient hospital settings, compared with 14 percent for mentally ill patients. Results suggest inefficient use of the health care system by mentally ill patients and highlight the need for coordination of care.     

Social and physical health of homeless adults previously treated for mental health problems

A total of 529 homeless adults in Los Angeles County were surveyed to determine the relationship between their previous use of mental health services and their physical health status, utilization of medical services, personal habits affecting health, experience of injury and victimization, and perceived needs. Homeless adults with a previous psychiatric hospitalization were more likely to have experienced serious physical symptoms during the previous month than those who had used only outpatient mental health services or who had never used mental health services. They reported more reasons for not obtaining needed medical care, were more likely to obtained food from garbage cans, and had the least adequate personal hygiene. However, they did not differ from the other groups on most measures of nutrition, social relations, and financial status. The most frequently expressed needs of the homeless were for improved social relations, employment, shelter, and money.