Limited English proficiency as a barrier to mental health service use: A study of Latino and Asian immigrants with psychiatric disorders

Language barriers pose problems in mental health care for foreign-born individuals in the United States. Immigrants with psychiatric disorders may be at particular risk but are currently understudied. The purpose of this study was to examine the effect of limited English proficiency (LEP) on mental health service use among immigrant adults with psychiatric disorders. Drawn from the National Latino and Asian American Study (NLAAS), Latino and Asian immigrant adults aged 18-86 with any instrument-determined mood, anxiety, and substance use disorder (n = 372) were included in the present analysis. Results from hierarchical logistic regression analyses showed that having health insurance, poor self-rated mental health, and more psychiatric disorders were independently associated with higher probability of mental health service use in the Latino group. After controlling for all background characteristics and mental health need factors, LEP significantly decreased odds of mental health service use among Latino immigrants. None of the factors including LEP predicted mental health service use among Asian immigrants, who were also the least likely to access such services. LEP was a barrier to mental health service use among Latino immigrants with psychiatric disorders. This study suggests that future approaches to interventions might be well advised to include not only enhancing the availability of bilingual service providers and interpretation services but also increasing awareness of such options for at least Latino immigrants. In addition, further investigation is needed to identify factors that can enhance access to mental health care services among Asians.     

Predictors of psychiatric hospitalization for adults with co-occurring substance and mental disorders as compared to adults with mental illness only

Predictors of psychiatric hospitalization, predisposing, enabling and need, of adults with co-occurring mental and substance disorders were compared to predictors for adults with a mental illness only. Research participants were 1613 users of crisis intervention services. Findings using Cox regression show that dually-diagnosed individuals were more likely to be hospitalized. Enabling and need factors were important predictors for both groups. Disruptive behavior was a predictor for dually-diagnosed clients but not for clients with mental illness only. Findings suggest that outpatient mental health services are less well equipped to address a psychiatric crisis when it was accompanied by substance use issues.     

Diagnostic profiles associated with use of mental health and substance abuse services among high-risk youths

This study examined use of mental health services by 947 high-risk youths in a publicly funded system of care to determine how single and comorbid diagnostic profiles (psychiatric and substance use disorders) were associated with use of a variety of types of formal and informal services. Use of professional services was most likely for youths with non-substance use psychiatric disorders, those with comorbid disorders, and those for whom high caregiver strain was reported. Use of informal services, such as peer support groups, was most likely for youths with substance use disorders, those with comorbid disorders, and those who had had police contact. Unmet need for mental health services was greatest among youth with substance use disorders only.     

Health service use among persons with comorbid bipolar and substance use disorders

OBJECTIVE: This study tested the hypothesis that patients with comorbid bipolar and substance use disorders use health services to a greater extent than patients with either bipolar or substance use disorder alone. METHODS: A retrospective chart review was conducted among patients who used health services at the Ralph H. Johnson Department of Veterans Affairs medical center in Charleston, South Carolina, and had bipolar disorder alone, substance use disorder alone, and comorbid bipolar and substance use disorders. Patients with a psychiatric admission between 1999 and 2003 were included in the study. Information was collected on the use of health services one year before and including the index admission. RESULTS: The records of 106 eligible patients were examined for this study: 18 had bipolar disorder alone, 39 had substance use disorder alone, and 49 had both bipolar and substance use disorders. Compared with the other two groups, the group with comorbid bipolar and substance use disorders was significantly more likely to be suicidal. Compared with the group with bipolar disorder alone, the group with comorbid disorders had significantly fewer outpatient psychiatric visits and tended to have shorter psychiatric hospitalizations. Among patients with an alcohol use disorder, those who also had bipolar disorder were significantly less likely than those with an alcohol use disorder alone to have had an alcohol-related seizure. Patients with comorbid bipolar and substance use disorders were significantly less likely than those with substance use disorder alone to be referred for intensive substance abuse treatment, even though both groups were equally likely to enter and complete treatment when they were referred. CONCLUSIONS: Despite significant functional impairment among patients with comorbid bipolar and substance use disorders, they had significantly fewer psychiatric outpatient visits than those with bipolar disorder alone and were referred for intensive substance abuse treatment significantly less often than those with substance use disorder alone.     

Lifetime use of mental health and substance abuse treatment services by incarcerated women felons

OBJECTIVE: This study examined the lifetime use of alcohol, drug, and mental health treatment services by recently incarcerated women prison inmates. METHODS: A total of 805 women entering a North Carolina prison for new felony charges in 1991 and 1992 were interviewed in person shortly after incarceration. The women were assessed for psychiatric disorders and lifetime use of substance abuse and mental health treatment services. Rates of service use were analyzed by inmate characteristics and were compared with rates for a sample of women in the community in North Carolina. RESULTS: The majority of women inmates reported a history of using substance abuse services or mental health services or both. Those with psychiatric disorders and prison recidivists were the most likely to have used such services. Rates of service use were substantially higher for the inmates than for the women in the community, even when the effects of having a psychiatric or substance use disorder were controlled for. CONCLUSIONS: Many of the incarcerated women in the study met lifetime criteria for alcohol, drug, and mental health disorders that were significantly related to their use of substance abuse and mental health treatment services. The majority of the inmates met criteria for a current disorder despite past treatment. Further research is needed to help in developing programs to reduce women inmates' alcohol, drug, and mental health problems.     

Prevalence of psychiatric disorders in New Zealand prisons: a national study

OBJECTIVE: The paper describes the methodologies and results obtained on a large cohort of prison inmates in New Zealand who were screened for psychiatric disorder. METHOD: All women and remanded male inmates in New Zealand prisons, and a randomly selected cohort of 18% of sentenced male inmates were interviewed. Interviewers used the Composite International Diagnostic Interview - Automated to establish DSM-IV diagnoses, and the Personality Disorders Questionnaire to identify personality disorder. All prisons in New Zealand were visited. RESULTS: The results indicate markedly elevated prevalence rates for major mental disorder in the prison population when compared with community samples. This is especially the case for substance misuse, psychotic disorders, major depression, bipolar disorder, obsessive- compulsive disorder and posttraumatic stress disorder. Of particular concern is not only the increased prevalence rates for schizophrenia and related disorders but also the high level of comorbidity with substance misuse disorders demonstrated by this group. While 80.8% of inmates diagnosed with bipolar disorder were receiving psychiatric treatment in the prison, only 46.4% of depressed inmates and 37% of those suffering from psychosis were receiving treatment. Maori inmates were grossly overrepresented in the remand, female and male sentenced inmate population compared with the general population. CONCLUSIONS: A significant increase in provision of mental health services is required to cope with the high number of mentally ill inmates. The level of need demonstrated by this study requires a level of service provision that is quite beyond the capacity of current forensic psychiatry services, Department of Corrections Psychological Services or the prison nursing and medical officers. The elevated rates of common mental disorders argues for the use of improved psychiatric screening instruments, improved assessment and treatment capacities in the prison and an increased number of forensic psychiatric inpatient facilities to care for those psychotic inmates who are too unwell to be treated in the prison.     

Multimodal treatment for ADHD among youths in three Medicaid subgroups: disabled, foster care, and low income

OBJECTIVE: This study compared the use of treatments for attention-deficit hyperactivity disorder (ADHD) among three distinct subpopulations of Medicaid-insured youths who have very different mental health needs and patterns of service use: those with federally documented disability, those in foster care, and those in families with low income. METHODS: This one-year, cross-sectional study of community mental health services used administrative data. Individuals who were younger than 20 years, who were continuously enrolled in one Mid-Atlantic state Medicaid program, and who had two or more medical encounters associated with an ADHD diagnosis in 1998 were identified (N=1,296). Measures of the use of mental health services were the number of different classes of psychopharmacologic medications, the psychopharmacologic regimen, and the combined use of pharmacotherapy and psychotherapy treatments (multimodal treatment). RESULTS: Use of multiple psychopharmacologic agents was greater in the disabled and foster care groups compared with the low-income group. Significantly fewer mental health provider visits, but greater use of stimulant treatment only, were observed in the low-income group compared with the other groups. Youths in the disabled group were significantly more likely than youths in the low-income group, but not more likely than youths in the foster care group, to receive multimodal treatments. Children in foster care were significantly more likely than those in the other groups to use a substance abuse service. CONCLUSIONS: Among a cohort of Medicaid-enrolled youths with ADHD, co-existing psychiatric disorders and complex psychopharmacologic treatments were more common in the disabled and foster care groups than in the low-income group. Youths with disabilities were significantly more likely than youths in the low-income group to receive multimodal treatment.     

Gender differences in re‐offending among psychiatrically examined Swedish offenders

Background The gender gap for violent offending is narrowing in the general population. Substance abuse and mental health problems are known risk factors for criminality. While substance abuse treatment has been associated with reduced risk of re‐offending, women seem less likely to engage than men. People misusing substances tend to be high users of emergency room (ER) services. Such use may be an indicator both of treatment failure for substance misuse and offending. Little is known about gender differences in this respect. Aims This study aims to test for gender differences in re‐offending, use of substance abuse treatment, and hospital ER visits among offenders referred for forensic psychiatric assessment in Sweden. Method The study used a longitudinal retrospective design. Data on all 31 women from a 2‐year (2000–2001) cohort of serious offenders referred for forensic psychiatric assessment in Stockholm county, and 31 men from the same cohort, were extracted from forensic service and national records. Selection of the men was by initial random sampling followed by matching on age and substance misuse. The two resulting samples were compared on health service use and re‐offending data between release and the census date (30 April 2004). Results There were no gender differences for violent re‐offending or for engagement in planned substance abuse treatment, in spite of longer time at risk for the men. Re‐offending was reduced for women but not men who did not present in the ER with physical health problems. Conclusions Our study is limited by sample size, although it included all women referred to the specialist forensic psychiatric service over 2 years, but it does indicate that differences between men and women in this situation are likely, and worthy of further study. The only way of achieving adequate sample sizes is likely to be through multi‐centre collaboration. Copyright © 2010 John Wiley & Sons, Ltd.     

Influence of comorbid alcohol and psychiatric disorders on utilization of mental health services in the National Comorbidity Survey.

OBJECTIVE: This study sought to determine how comorbidity of psychiatric and substance abuse disorders affects the likelihood of using mental health services. METHOD: The analysis was based on data on adults aged 18-54 years in the National Comorbidity Survey (N = 5,393). Users and nonusers of mental health and substance abuse services were compared in terms of their demographic characteristics, recent stressful life events, social support, parental history of psychopathology, self-medication, and symptoms of alcohol abuse/dependence. RESULTS: The prevalence of service utilization varied by diagnostic configurations. Comorbid psychiatric or alcohol disorders were stronger predictors of service utilization than a pure psychiatric or alcohol disorder. Factors predicting utilization of services differed for each disorder. CONCLUSIONS: Since comorbidity increases the use of mental health and substance abuse services, research on the relationship of psychiatric and alcohol-related disorders to service utilization needs to consider the coexistence of mental disorders. Attempts to reduce barriers to help seeking for those in need of treatment should be increased.     

Personality disorder and pathways to inpatient psychiatric care

Background The impact of personality disorder on pathways into psychiatric care is unknown. Aim To examine associations between personality disorder status, length of pathway into inpatient psychiatric care, and involvement of the criminal justice service in the pathway into care. Method The Structured Clinical Interview for DSM-IV personality disorders (SCID-II) and a modified WHO Pathways Encounter Form were administered to a sample of 153 consecutive inpatients admitted to acute wards in one inner London borough over a 4-month period. Diagnosis, socio-demographic variables, social support and substance misuse were also ascertained. Results The presence of personality disorder was not associated with significant differences in the number of carers, time spent along the pathway, or probability of criminal justice system involvement. However, all three personality disorder clusters were significantly associated with increased use of Accident and Emergency (A & E) services. Conclusion Given the high levels of contact with A & E services, casualty staff should receive improved training in the assessment and management of patients with personality disorders. Improved detection of personality disorder within A & E departments could lead to earlier diversion to mental health services and a consequential improvement in the planning of subsequent treatment.     

Long-term use of VA mental health services by older patients with substance use disorders

OBJECTIVE: The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system. METHODS: In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders. RESULTS: Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions. CONCLUSIONS: Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.     

How does drug and alcohol misuse develop among people with psychotic illness? A literature review

Background: There is little evidence contributing to the understanding of why people with schizophrenia and other psychotic illnesses use drugs and alcohol. Method: A comprehensive literature search for evidence relevant to each of the following questions was undertaken, each of which is relevant to understanding why individuals with schizophrenia and other functional psychotic illnesses use drugs and alcohol: (1) Is substance misuse more prevalent among those with psychotic illness than the general Population? (2) Which problem generally develops first in dual diagnosis? (3) Can substance misuse cause schizophrenia and other functional psychotic illnesses? (4) Does dual diagnosis have a neurobiological Basis? (5) Is personality disorder a mediating factor in the relationship between psychotic illnesses and substance misuse? (6) Do individuals with psychotic illness use substances as self-medication? (7) Have changes in the care and social circumstances of people with psychotic illness, particularly deinstitutionalisation, led to a rise in substance misuse in this Population? (8) Do the social situations and social difficulties of people with psychotic illness lead to substance misuse? and (9) Do individuals with psychotic illness tend to begin using drugs and alcohol within mental health service settings or in the company of other users of such services? Results: There is some evidence to support the idea that people with schizophrenia and other psychotic disorders use substances to reduce general dysphoria, and possibly negative symptoms. Social environment and experiences are also likely to be factors in the development of substance misuse in this group, but there is a dearth of empirical evidence. Conclusions: There is a need for further research, especially concerning the social contexts of substance and alcohol misuse and the ways in which patterns of misuse develop among people with schizophrenia and other psychotic illnesses.     

Factors associated with high use of public mental health services by persons with borderline personality disorder

OBJECTIVE: The research presented here was a pilot study to identify clinical factors associated with high use (as opposed to lower use) of inpatient psychiatric services by persons with borderline personality disorder. METHODS: The initial sample was a random sample of English- and Spanish-speaking persons aged 18 to 60 years who had received at least one outpatient mental health service in the previous 90-day period and were enrolled in one of the participating mental health centers in King County, Washington. A random sample of persons who met selection criteria was randomly drawn; persons with high levels of use were oversampled to ensure adequate representation. Twenty-nine participants met full criteria for borderline personality disorder on the Personality Disorders Examination structured interview and completed all measures. Fifteen (52 percent) of these had a high level of use of inpatient services, and 14 did not. RESULTS: High use of inpatient psychiatric services was predicted by a history of parasuicide in the previous two years but not by the number or severity of parasuicides; by the presence and number of anxiety disorders but not by depression or psychotic or substance use disorders; and by poorer cognitive functioning. Life stressors, global functioning, and health service variables did not differentiate patients with high levels of service use from other patients with borderline personality disorder. CONCLUSIONS: Further research should explore these predictors of service use to determine whether they are replicated in larger samples, and treatments that target these variables should be evaluated.     

Full spectrum of mental disorders linked with childhood residential mobility

Although links between childhood residential mobility and subsequently increased risks of psychopathology have been well documented, associations across the full spectrum of psychiatric disorders are unknown. We conducted a population-based study of all 1,439,363 persons born in Denmark during 1971–1997 to investigate relationships between childhood cross-municipality residential moves from year of birth to age 14 years and the development of a range of psychiatric disorders from mid-adolescence to early middle age. We examined: (1) Any substance misuse disorders; specifically alcohol misuse, and cannabis misuse; (2) Any personality disorders; specifically antisocial, and borderline personality disorders; (3) Schizophrenia and related disorders; specifically schizophrenia, and schizoaffective disorder; (4) Any mood disorders; specifically bipolar disorder, and depressive disorder; (5) Any anxiety and somatoform disorders; specifically obsessive compulsive disorder; (6) Any eating disorders; specifically anorexia nervosa. Childhood residential mobility was associated with elevated risks of developing most psychiatric disorders, even after controlling for potential confounders. The associations generally rose with increasing age at moving and were stronger for multiple moves in a year compared to a single move. Links were particularly strong for antisocial personality disorder, any substance misuse disorder, and cannabis misuse in particular, for which the highest increases in risks were observed if relocation occurred during adolescence. Childhood residential change was not linked to subsequent risk of developing an eating disorder. Frequent residential mobility could be a marker for familial adversities. Mental health services and schools need to be vigilant of the psychosocial needs of children, particularly adolescents, who have recently moved homes.     

Three year course and outcome of mental illness in homeless men

OBJECTIVE: To report on the 3-year course and outcome of mental illness and social aspects in a representative sample of 265 homeless men living on the street or using overnight shelter. METHOD: Expert interviews at baseline and at follow-up included the SCID-I and covered cognitive impairment, somatic complaints, use of medical services and psychosocial areas. Of 247 homeless men still alive, at 3-year follow-up, 185 (74.9 %) were successfully traced and interviewed face to face. RESULTS: There was considerable improvement regarding the housing situation after 3 years. Rates of mental illness decreased from 79 % to 66% over 3 years possibly due to an improved housing situation and increased medical/psychiatric attention and service. The prevalence of mood disorders, substance use disorders and anxiety disorders was significantly lower at 3-year follow-up while psychotic disorders showed a slight increase over time. Thus, in general, more remission than incidence was observed in the 3-year follow-up period. A high rate of use of general medical inpatient services was found. Considering the very high prevalence of mental illness, the use of psychiatric services was very low with some increase over time. Mental health status at 1st assessment did not predict the housing situation at 3 year follow-up. Having had a substance use disorder diagnosis at 1st assessment was a powerful predictor of an unfavorable mental health status at 3 year follow-up. Standardized mortality ratio over 3 years was 4.4.     

Pharmacological issues in the management of people with mental illness and problems with alcohol and illicit drug misuse

BACKGROUND: While there is plentiful information on the pharmacological management of detoxification from alcohol and on withdrawal from or maintenance of opiates for people with a principal problem of substance misuse or dependency, the pharmacological management of substance misusers presenting with a mental illness can be more complicated. Mental health and substance misuse services tend to be separate, but there is now a drive to increase effective overlap between them by equipping mental health clinicians with the skills and confidence to manage substance misuse disorders in conjunction with major mental illness. AIMS: This paper aims to highlight, for a multi-professional readership, some of the prescribing options and precautions to consider when psychotropic medicines are prescribed for treatment of a mental illness in someone who may continue to use illicit substances or alcohol. It also considers interactions with the completely licit substances, nicotine and caffeine. With recent legislation prohibiting smoking in public places people are likely to reduce or stop smoking, which can have a substantial effect on the levels of medication in their blood.     

Psychiatric disorders and their comorbidity in subjects with parasuicide by intentional drug overdose: prevalence and gender differences

The aims of the present study were to assess the prevalence and comorbidity of psychiatric disorders in subjects with intentional drug overdose and to explore whether there were gender differences in prevalence and comorbidity. A standardized psychiatric evaluation was performed in 100 randomly selected subjects, 18 years old and older, with intentional drug overdose referred to an emergency department. The prevalences of psychiatric morbidity and comorbidity were very high in both genders: 88% presented with at least one psychiatric diagnosis, and three-quarters presented with comorbid psychiatric disorders. Affective and anxiety disorders were the most prevalent diagnoses. One patient out of three presented with alcohol or substance misuse. Compared to females, males suffered five times more often from substance misuse and three times more often from psychotic syndrome and were three times less likely to present with anxiety disorder. When subjects are referred to hospital for intentional drug overdose, medical management should systematically involve a psychiatric assessment in order to identify not only affective and anxiety disorders, but also alcohol and substance misuse, due to the high prevalence of these disorders, especially in male subjects.     

Dual diagnosis in the suburbs: prevalence, need, and in-patient service use

  Background: Previous research has found comorbid severe mental illness and substance misuse (dual diagnosis) to be highly prevalent and to be associated with serious clinical and social problems, and increased service use in inner-city populations. The present study measures the prevalence of dual diagnosis, patterns of substance misuse, and associated in-patient use in a more demographically representative population in a suburban area of South London Method: We identified representative prevalent cases with psychotic illnesses who had been in contact with services in a geographically defined catchment area in Croydon over the previous 6 months. Cases of alcohol or substance misuse and dependence were identified through standardised interviews with patients and keyworkers, and socio- demographic and in-patient psychiatric service use data were also recorded. Results: Sixty-one of the 124 cases identified were randomly selected for interview, of whom 66% responded (N = 40). The prevalence rates of dual diagnosis (DD) observed were 33% (95% CI 18–47%) for any substance misuse, 20% (95% CI 8–32%) for alcohol misuse only, 5% (95% CI −16 to 26%) for drug misuse only, and 8% (95% CI −0.7 to 16%) for both drug and alcohol misuse. A lifetime history of any illicit drug use was observed in 35% of the sample (95% CI 20–50%). Patients who misuse alcohol and drugs were not found to be more likely to have been admitted to hospital in the previous 2 years, with little difference being observed between DD and psychosis-only patients in the mean number of in-patient admissions in this period (mean difference 0.25, 95% CI for difference −1.5 to 2.0). However, the DD patients were found to have spent on average over twice as long in hospital as other psychotic in-patients over the previous 2 years (mean difference 67.3 days, 95% CI for difference −205.9 to 71.2 days). DD patients were also found to have a greater number of unmet areas of need than the psychosis-only patients, which included accommodation, daytime activity, and social life, as well as substance misuse. Conclusions: The prevalence of substance misuse in patients with severe mental disorders in a suburban area is about as high as that for similar patients in inner-city London. While DD patients are not admitted more often than patients with psychosis alone, they have double the length of in-patient stay, which may be attributable to higher levels of unmet need. Accepted: 6 April 2000     

A profile of problem drinkers in public mental health services.

Psychiatric patients with alcohol problems are generally considered more challenging to treat and more demanding of public psychiatric services than other patients. This study of new admissions to a county mental health system in California examined differences between problem drinkers and nonproblem drinkers in clinical and demographic characteristics and in the demands they placed on services. Problem drinkers experienced more severe emotional distress at intake; were more likely to have financial, legal, and employment problems; and were more likely to be involved with illicit drugs. They made greater demands on clinical resources and also required more social services, such as income supports, case management, and vocational services. The study indicates that to meet the varied needs of psychiatric patients with drinking problems, public mental health services should develop stronger ties not only with substance abuse services but also with social service and criminal justice agencies.     

Utilization of alcohol, drug, and mental health treatment services among American Indian adolescent detainees.

OBJECTIVE: To describe the relationship between psychiatric status and the use of alcohol, drug, and mental health (ADM) services among a sample of American Indian (AI) juvenile detainees. METHOD: A structured diagnostic and service use interview was administered to 150 AI youths detained in a juvenile detention center located on a Northern Plains reservation. RESULTS: Forty percent of AI youths with a diagnosed substance use disorder and 34.1% with a diagnosed anxiety, mood, or disruptive behavior disorder reported lifetime use of services for substance use and emotional problems, respectively. While services for substance use problems were most commonly provided in residential settings, services for emotional problems were most commonly provided in outpatient settings. Traditional healers and pastoral counselors provided services to 23.7% and 29.6% of youths who received services for substance use and emotional problems, respectively. Detained youths were more likely to receive ADM services than AI adolescents living at--large in another, comparable Northern Plains reservation community. Still, the vast majority of youths in detention who suffered from psychiatric disorders did not report use of ADM services. CONCLUSIONS: Detention facilities serving AI adolescents need to screen carefully for the presence of psychiatric disorders and facilitate the use of ADM services.