Characteristics of subgroups of individuals with psychotic illness and a comorbid substance use disorder

OBJECTIVES: The co-occurrence of severe mental illness and substance use disorder, or dual diagnosis, is prevalent and is associated with significant clinical and social problems. Most studies have treated persons with a dual diagnosis as a homogeneous population, grouping together different substances of misuse. This study investigated whether subgroups defined by their main substances of misuse were heterogeneous. The primary hypothesis was that users of stimulants, such as cocaine or amphetamines, would be characterized by especially high rates of inpatient admission, violence, and self-harm. METHODS: Case managers' ratings were used to identify individuals with serious mental illness and comorbid substance abuse or dependence who were being treated by 13 community mental health teams in South London. Standardized instruments were used to elicit sociodemographic, clinical, social, and service use data. RESULTS: A total of 233 cases of comorbid substance use disorder and psychotic illness were identified. On the basis of best available information, 78 (34 percent) patients were classified as alcohol misusers only, 52 (22 percent) as alcohol and cannabis users, 29 (12 percent) as users of cannabis only, and 55 (24 percent) as stimulant users; 19 patients (8 percent) were excluded from the analysis. No significant differences were found between subgroups in the use of inpatient services and lifetime history of self-harm, but there was a significant difference in lifetime history of violence, which was more frequent among stimulant users. The alcohol users were older and more likely to be white, but otherwise few differences between subgroups were suggested by exploratory analyses. CONCLUSIONS: Apart from differences in history of violence, little heterogeneity was found among subgroups of patients with different types of substance misuse.     

Increasing rates of suicide in Western Australian psychiatric patients: a record linkage study.

OBJECTIVE: To investigate the risk of suicide following contact with mental health services and whether it has changed over time. METHOD: Record linkage was used to obtain the records of previous hospital admissions and mental health service contacts for deaths due to suicide in the period 1980-98. Standardized incidence rates were calculated for the general population and for users of mental health services. Proportional hazards regression was used to assess risk factors within the cohort of people with mental health service contact. RESULTS: Suicide risk was significantly increased in users of mental health services (rate ratio 6.66 in males and 7.52 in females). Suicide risk was highest in the first 7 days after discharge from in-patient care, and decreased exponentially with time since discharge. Suicide risk in users of mental health services has increased over the study period. CONCLUSION: These results highlight the importance of adequate follow-up of patients discharged from in-patient services, and the need for adequate resources for community-based services.     

Social networks and their relationship to mental health service use and expenditures among Medicaid beneficiaries

OBJECTIVE: This study examined the relationship between social networks and mental health services utilization and expenditures. METHODS: A sample of 522 Medicaid mental health consumers was randomly selected from the administrative records of Colorado's Department of Health Care Policy and Financing. The administrative records contain information on utilization of services and expenditures of Medicaid beneficiaries within Colorado's Mental Health Services. In addition to the administrative records, social network and psychosocial data were gathered through longitudinal survey interviews. The interviews were conducted at six-month intervals between 1994 and 1997. Measures used in the regression analysis included demographic characteristics, clinical diagnoses, the social network index, expenditures, and utilization variables. RESULTS: The social network index was positively associated with utilization of and expenditures for inpatient services in local hospitals but negatively associated with expenditures for inpatient services in state hospitals or outpatient services. Relationships with family were negatively related to expenditures for outpatient services. Relationships with friends were positively associated with utilization of and expenditures for psychiatric inpatient services in local hospitals. CONCLUSIONS: Consumers who had higher social network index scores utilized more inpatient psychiatric services in local hospitals and had higher expenditures than those who had lower scores. Consumers who had higher social network index scores also had lower expenditures for inpatient services in state hospitals and outpatient services than those who have lower scores. Findings suggest that social network is associated with mental health utilization and expenditures in various ways, associations that need to be researched further.     

Factors contributing to frequent use of psychiatric inpatient services by schizophrenia patients

Abstract. Background: Although present findings about frequent users of psychiatric inpatient services vary from study to study, some potentially important predictors of frequent use were extracted. The purpose of this study was to examine the potentially contributory factors of frequent use of psychiatric inpatient services by schizophrenia patients and to test the influence single factors have in an overall model. Methods: A total of 307 schizophrenia patients were interviewed five times with intervals of 6 months. Data were collected about service receipt and health care costs, strength of primary diagnosis and comorbidities, as well as about patients needs for care and satisfaction with care. Patients with three or more psychiatric admissions within a 30-month period were defined as frequent users. Results: According to this criterion, 12% of the study population were frequent users. Compared with ordinary users, these patients accounted for significantly higher costs in hospital- and community-based care. Important predictors for frequent use of psychiatric inpatient services were the number of previous hospitalizations and current scores of psychopathology. In addition, a longitudinal analysis showed the importance of social factors for the use of psychiatric inpatient care. Therefore, a number of the frequent users multiple admissions could also be caused by social problems. Conclusions: The mental health system should, thus, provide well-directed community-based resources, which give frequent users support to solve their social problems.     

Specialty and general ambulatory mental health services. Comparison of utilization and expenditures

A substantial amount of ambulatory mental health services are received outside of the specialty mental health sector; however, precise estimates are lacking. To determine national estimates of utilization and expenditures for total ambulatory mental health services, as well as separate estimates for the specialty mental health and general medical sectors, patterns of use were examined by standard demographic characteristics. Almost 5% of the US population in 1977 had at least one ambulatory visit in conjunction with a mental problem. Three fifths of users received their care in the general medical sector; however, two thirds of all mental health visits occurred in the specialty mental health sector. This study indicates that there are significant differences between the two sectors with respect to utilization and expenditure patterns.     

Mental disorders and quality of diabetes care in the veterans health administration

OBJECTIVE: The population of persons with mental disorders is potentially vulnerable to poor quality of medical care. This study examined the relationship between mental disorders and quality of diabetes care in a national sample of veterans. METHOD: Chart-abstracted quality data were merged with outpatient and inpatient administrative database records for a sample of veterans with diabetes who had at least three outpatient visits in the previous year (N=38,020). Mental health diagnoses were identified by use of the administrative data. Quality of diabetes care was assessed with five indicators by chart documentation: annual foot inspection, pedal pulses examination, foot sensory examination, retina examination, and glycated hemoglobin determination. RESULTS: Approximately a quarter of the sample had a diagnosed mental disorder (23.7% with psychiatric disorder only, 1.3% with substance use disorder only, and 2.6% with a dual diagnosis). Overall rates of receipt for the indicators were higher than national benchmarks for all patient subgroups, ranging from 70.8% for retina examination to 95.0% for foot inspection. Rates for both retina examination and foot sensory examination differed significantly by mental health status, mainly because of lower rates among those with a substance use disorder. The associations remained significant in multivariate generalized estimating equation analyses that controlled for demographic characteristics, health status, use of medical services, and hospital-level characteristics. CONCLUSIONS: Rates for secondary prevention of diabetes were remarkably high at Department of Veterans Affairs medical centers, although patients with mental disorders (particularly substance use disorders) were somewhat less likely to receive some of the recommended interventions.     

Trends in discharge disposition,mortality, and service use among long-stay psychiatric patients in the 1990s

OBJECTIVE: This study examined changes in discharge disposition, mortality, and service use among three cohorts of highly vulnerable long-stay psychiatric patients in the Department of Veterans Affairs (VA) mental health system during the 1990s, a period of extensive bed closures. METHODS: National VA administrative databases were used to identify and prospectively follow three long-stay cohorts: mental health inpatients who had been hospitalized for at least one year as of the end of fiscal year 1991 (N=2,343), 1994 (N=1,853), and 1997 (N=1,156). The cohorts were compared in baseline demographic and diagnostic characteristics as well as discharge disposition, mortality, and service use over a three-year follow-up period. RESULTS: Nationally, the number of occupied long-stay beds decreased by 50 percent between 1991 and 1997. Over time, significant changes were noted in long-stay patients' principal diagnoses and discharge dispositions. Compared with the 1991 cohort, the 1994 and 1997 cohorts had a higher proportion of patients with psychotic disorders (69 percent, 77 percent, and 75 percent, respectively) and were more likely to be discharged from the hospital during the three-year follow-up period (33 percent, 54 percent, and 53 percent, respectively). However, among patients who were discharged, no substantial differences were noted in either mortality or overall VA service use across the three cohorts. CONCLUSIONS: The delivery of inpatient VA mental health services changed dramatically during the 1990s. This study provided evidence that continuing efforts to close VA mental health beds have not resulted in substantially adverse changes in mortality rates or in the extent to which long-term inpatients remain connected with the VA system after discharge.     

Single and repeated admissions to a mental health center: demographic, clinical and use of service characteristics.

Eight hundred and forty one patients with 1,135 consecutive admissions to a university-affiliated mental health center were studied to examine patterns of treatment program use. Twenty two percent of patients had repeat admissions accounting for 42% of hospital episodes. Single admission and repeater groups are compared, and differences among repeater subgroups with progressively greater numbers of admissions per patient are described. Only 10 patients with the highest number of admissions during the study period also were very high utilizers of all services (inpatient, crisis, day hospital, regional chronic state hospital). These patients' characteristics are discussed with implications for future study.     

Bed closures and incarceration rates among users of Veterans Affairs mental health services

OBJECTIVE: This study examined incarceration rates of users of Department of Veterans Affairs (VA) mental health services in 16 northeastern New York State counties between 1994 and 1997-a time of extensive bed closures in the VA system-to determine whether incarceration rates changed during this period. METHODS: Data were obtained for male patients who used inpatient and outpatient VA mental health services between 1994 and 1997 and for men incarcerated in local jails during this period. For comparison, services use and incarceration data were obtained for all men who received inpatient behavioral health care at community general hospitals and state mental hospitals between 1994 and 1996 in the same counties. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between clinical and incarceration populations without relying on person-specific identifiers. RESULTS: Of all male users of VA mental health services between 1994 and 1997, a total of 15.7 percent-39.6 percent of those age 18 to 39 years and 9.1 percent of those age 40 years and older-were incarcerated at some time during that period. Dual diagnosis patients had the highest rate of incarceration (25 percent), followed by patients with substance abuse problems only (21 percent) and those with mental health problems only (11 percent). The rate of incarceration among male patients hospitalized in VA facilities was lower than among men in general hospitals or state hospitals (11.6 percent, 23 percent, and 21.7 percent, respectively), but was not significantly different. No significant increase occurred in the annual rate of incarceration among VA patients from 1994 to 1997 (3.7 percent to 4 percent), despite extensive VA bed closures during these years. CONCLUSIONS: Substantial proportions of mental health system users were incarcerated during the study period, especially younger men and those with both substance use and mental health disorders. Rates of incarceration were similar across health care systems. The closure of a substantial number of VA mental health inpatient beds did not seem to affect the rate of incarceration among VA service users.     

An advocacy model for people with long-term psychiatric disabilities

Traditional rights protection and advocacy systems in the mental health field have focused primarily on the use of legal processes to protect patients in inpatient settings. This paper describes a study of an advocacy model designed to help frequent users of mental health services adjust more successfully to community living. Clients who were offered advocacy services related to self-identified problems and needs were compared with a control group who were not offered the services. During the study period clients who received the advocacy services were hospitalized significantly fewer days than the control group with no increase in psychiatric symptoms, but the differences between the two groups disappeared after advocacy services were terminated. The authors compare the advocacy intervention to case management and discuss the potential role of advocacy services in mental health systems.     

Does Closing Inpatient Beds in One Public Mental Health System Result in Increased Use of Hospital Services in Other Systems?

This study of users of Department of Veterans Affairs (VA) behavioral health services examines changes in their use of non-VA inpatient services from 1994 to 1997, a period of extensive VA bed closures. Data on service use were obtained on New York State residents who used VA behavioral health services and on residents who were hospitalized for behavioral health care at community general hospitals and state mental hospitals. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between VA mental health and non-VA inpatient populations without relying on person-specific identifiers. Annually, on average, 6% of VA behavioral health service users were hospitalized in either general hospitals in New York State or state mental hospitals: 4% of psychiatric patients, 10% of substance abuse patients, and 11% of dually diagnosed patients. Overall rates of cross system use did not change significantly from 1994 to 1997. Cross-system use of inpatient services is limited and was not affected by the closure of one-third of all VA mental health beds, most likely because of an increased supply of VA outpatient services.     

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.     

The identification of trends in the utilisation of mental health services by elderly: a Dutch case register study

OBJECTIVE: In view of the rapid ageing of the population any changes in the use of mental health services by the elderly became increasingly important for policy development. This study aimed at the supply of information about trends in the numbers of elderly clients, the services they used and the volume and pattern of service utilisation. METHODS: Details of elderly users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. Developments in population size and age distribution in the register area were taken into account, as were the unit costs of mental health services. RESULTS: Large age specific changes were found that caused only the expenditures on the oldest elderly to increase due to a shift from outpatient clinics to prolonged psychogeriatric day treatment and inpatient care. Comparatively young elderly used fewer inpatient services and more community care. The number of new elderly clients declined progressively. In some age groups treated prevalence also decreased, but to a lesser extent, because of a prolonged use of mental health services. CONCLUSIONS: Study results seemed well in accordance with mental health policy as to deinstitutionalization and active ageing. Research on the effect of mental health care on life expectancy and the time lag between the intake of mental health providers and treated prevalence was proposed in order to improve the prediction of future service use by elderly.     

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.     

Change in Dutch mental health care: an evaluation

  Background: In the Netherlands there has been no distinct period of deinstitutionalization or transinstitutionalization of mental health care. Rather, the Dutch government expects local mental health services to reform their joint service provision without forceful measures like cutting budgets of large mental hospitals. This study aimed at quantifying gradual changes in the use of community- and hospital-based care. Methods: The Groningen psychiatric case register was used to determine the number of users and the amount of use of mental health services. Changes in population size and age distribution were accounted for by means of demographic data. Results: The number of users of innovative psychiatric treatment modalities more than tripled between 1989 and 1997. In the same period, the volume of traditional inpatient care gradually decreased. This was caused primarily by a reduction in the length of stay in the hospital. Conclusions: These findings seem to support the effectiveness of Dutch substitution policy. However, there is also a cause for concern. Though people use new mental health care provisions, there is a rapidly growing number of them who do so. Accepted: 15 May 2000     

Assertive outreach for frequent users of psychiatric hospitals: a meta-analysis

A meta-analysis was conducted on nine studies of an assertive outreach model for frequent users of psychiatric hospitals. Four studies used experimental or quasi-experimental designs and five used pre-post designs. Findings at one-year follow-up were examined for retention in community mental health services, psychiatric inpatient days, quality of life, and client level of functioning. Eighty-four percent of assertive outreach clients were still receiving mental health services after one year, compared to 54% of controls. In two thirds of the programs, the mean annual rate of inpatient days declined by 50% or more. The overall experimental effect size for quality of life was negligible, although changes over time for assertive outreach clients were more encouraging. Similarly, improvement in level of functioning was found for assertive outreach clients. The study examining experimental differences in level of functioning obtained a nonsignificant moderate effect.     

The Impact of Integrating Crisis Teams into Community Mental Health Services on Emergency Department and Inpatient Demand

This investigation focused on the impact of integrating crisis team members into community mental health services on emergency department and adult mental health inpatient unit demand within an Australian public health service. Mixed methods were used including (a) the comparison of service use data with that of two other comparable services (both of which had community-based crisis teams), (b) surveys of (i) patients and carers and (ii) staff, and (c) focus groups with staff. The numbers of emergency department presentations with mental health conditions and adult mental health inpatient separations increased 13.9 and 5.7 %, respectively, from FY2006/07 to FY2012/13. Between the three services, there were minimal differences in the percentages of presentations with mental health conditions, the distribution of mental health presentations across a 24-h period, and the triage categories assigned to these patients. Survey participants reported that patients used the emergency department due to the urgency of situations, perceptions that gaining access to mental health services would take less time, and the unavailability of mental health services when help is needed. Staff identified several issues (e.g. inappropriate referrals) that may be unnecessary in increasing emergency department demand. The integration of crisis team members into community mental health services does not seem to have produced an increase in emergency department admissions or inpatient separations beyond what might be expected from population growth. The potential may exist, however, to reduce emergency department admissions through addressing the issue of inappropriate referrals.     

Characteristics and service use patterns of nonelderly medicare beneficiaries with schizophrenia.

OBJECTIVE: The authors sought to describe the characteristics of nonelderly Medicare beneficiaries who have a diagnosis of schizophrenia and to assess the impact of Medicare financing on service quality by comparing service use among individuals who were enrolled only in Medicare and those who were enrolled in both Medicare and Medicaid. The authors hypothesized that persons who received only Medicare benefits would use proportionally fewer psychosocial services and less antipsychotic medication than individuals who were dually enrolled. METHODS: Data were drawn from the Medicare Current Beneficiary Survey (MCBS). The study sample consisted of 257 individuals younger than age 65 who were included in the 1995 MCBS sample and who had one inpatient or two outpatient claims for schizophrenia between 1992 and 1996. The variables examined were demographic characteristics, comorbid psychiatric and substance use disorders, activities of daily living, instrumental activities of daily living, self-reported use of prescribed antipsychotic medication, and claims for psychosocial services. A multivariate analysis was also conducted to predict the use of antipsychotic medication from demographic and health status variables. RESULTS: Dually enrolled beneficiaries were significantly more likely to be receiving antipsychotic medication than Medicare-only beneficiaries, even when the analysis controlled for demographic characteristics, health status, and comorbidity. No significant differences were found in the use of psychosocial services. CONCLUSIONS: The findings were consistent with the hypothesis that Medicare financing, which restricts access to many mental health services, is not conducive to good community care for persons with schizophrenia.     

Association between interruptions in medicaid coverage and use of inpatient psychiatric services

OBJECTIVES: Persons with schizophrenia are heavy and persistent users of Medicaid services. Interruptions in their Medicaid coverage may have serious consequences for the mental health of these individuals and their subsequent use of mental health services. This study sought to determine the impact of interruptions in Medicaid coverage on the use of Medicaid-reimbursed inpatient psychiatric services over a four-year period. METHODS: Inpatient Medicaid claims and eligibility files for 1,830 Medicaid beneficiaries with schizophrenia in Utah from December 1990 to December 1994 were used to identify differences in hospital admissions and total number of days in a hospital associated with interrupted Medicaid coverage. Of the 1,830 Medicaid beneficiaries identified, 1,463 experienced continuous Medicaid eligibility, and 367 had interruptions in their eligibility. RESULTS: Interruptions in Medicaid coverage were associated with an average of.63 more psychiatric hospitalizations per beneficiary over the four-year period, representing an 86 percent higher hospital admission rate. This increase appeared to be largely due to a subset of persons who have much higher hospitalization rates after an interruption in Medicaid coverage. Interruptions in Medicaid coverage were associated with a mean of 8.3 more days of psychiatric hospitalization over the four-year period, representing 61 percent more hospital days. CONCLUSIONS: Medicaid beneficiaries who experience interruptions in coverage have, on average, a significantly greater use of inpatient psychiatric services while participating in Medicaid than beneficiaries with continuous Medicaid coverage. These findings suggest potential benefits of maintaining continuous Medicaid eligibility for beneficiaries with a severe mental illness.     

The impact of managed care on cross-system use of mental health services by veterans in Colorado

OBJECTIVES: Some state mental health systems have implemented capitated managed care as a strategy for lowering mental health care costs. There has been concern that this strategy has left vulnerable populations at risk of not being able to obtain adequate care. This study examined whether the advent of managed care in Colorado resulted in lower rates of use of both state and Department of Veterans Affairs (VA) mental health care services (cross-system use). METHODS: A cohort of 10,950 veterans who had used VA mental health services between 1995 and 1997 were studied to determine whether veterans who lived in counties that had implemented managed care were less likely to be cross-system users over time. VA data were matched with state mental health data to determine who was using both types of services. RESULTS: Rates of cross-system use were generally low. Veterans who lived in a county that had implemented managed care were less likely to be cross-system users than veterans who lived in other counties. However, the proportions of cross system users in managed care counties and in other counties did not change significantly over time. Veterans who were cross-system users were more likely to be younger, to live farther away from a VA hospital and closer to a non-VA hospital, and to have received inpatient VA care. CONCLUSIONS: The implementation of managed care in Colorado did not appear to have affected rates of cross-system use of state and VA mental health care.