Mental health care use in adolescents with and without mental disorders

The aim of the study was to estimate the proportion of adolescents with and without a psychiatric diagnosis receiving specialist mental health care and investigate their problem levels as well as utilization of other types of mental health care to detect possible over- and undertreatment. Care utilization data were linked to psychiatric diagnostic data of 2230 adolescents participating in the TRAILS cohort study, who were assessed biannually starting at age 11. Psychiatric diagnoses were established at the fourth wave by the Composite International Diagnostic Interview. Self-, parent- and teacher-reported emotional and behavioral problems and self-reported mental health care use were assessed at all four waves. Of all diagnosed adolescents, 35.3 % received specialist mental health care. This rate increased to 54.5 % when three or more disorders were diagnosed. Almost a third (28.5 %) of specialist care users had no psychiatric diagnosis; teachers gave them relatively high ratings on attention and impulsivity subscales. Diagnosed adolescents without specialist mental health care also reported low rates of other care use. We found no indication of overtreatment. Half of the adolescents with three or more disorders do not receive specialist mental health care nor any other type of care, which might indicate unmet needs.     

Perceived unmet need for mental health care for Canadians with co-occurring mental and substance use disorders

OBJECTIVE: Previous analyses demonstrated an elevated occurrence of perceived unmet need for mental health care among persons with co-occurring mental and substance use disorders in comparison with those with either disorder. This study built on previous work to examine these associations and underlying reasons in more detail. METHODS: Secondary data analyses were performed on a subset of respondents to the 2002 Canadian Community Health Survey (unweighted N=4,052). Diagnostic algorithms classified respondents by past-year substance dependence and selected mood and anxiety disorders. Logistic regressions examined the associations between diagnoses and unmet need in the previous year, accounting for recent service use and potential predisposing, enabling, and need factors often associated with help seeking. Self-reported reasons underlying unmet need were also tabulated across diagnostic groups. RESULTS: Of persons with a disorder, 22% reported a 12-month unmet need for care. With controls for service use and other potential confounders, the odds of unmet need were significantly elevated among persons with co-occurring disorders (adjusted odds ratio=3.25; 95% confidence interval=1.96-5.37). Most commonly, the underlying reason involved a preference to self-manage symptoms or not getting around to seeking care, with some variation by diagnosis. CONCLUSIONS: The findings highlight potential problems for individuals with mental and substance use disorders in accessing services. The elevated occurrence of perceived unmet need appeared to be relatively less affected by contact with the health care system than by generalized distress and problem severity. Issues such as stigma, motivation, and satisfaction with past services may influence help-seeking patterns and perceptions of unmet need and should be examined in future work.     

Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents

OBJECTIVE: To focus attention on the critical unmet needs of children and adolescents with mood disorders and to make recommendations for future research and allocation of healthcare resources. METHOD: The 36-member Consensus Development Panel consisted of experts in child/adolescent or adult psychiatry and psychology, pediatrics, and mental health advocacy. Reviews of the literature concerning youth mood disorders were performed on the subjects of risk factors, prevention, diagnosis, treatment, and services delivery, and opinions and experiences of mental health advocates were obtained. RESULTS: The Consensus Development Panel listened to presentations and participated in discussions. Independent workgroups of clinicians, scientists, and mental health advocates considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed by the entire group and edited to incorporate input from all participants. CONCLUSIONS: Evidence suggests high rates of unmet needs for children and adolescents with depression or bipolar disorder. Training is largely limited to child mental health specialists; general psychiatrists, pediatricians, and other primary care physicians receive little or no training. As a result, treatment patterns may reflect adult treatment plans that are not validated for youths. Effective treatments have been identified and some preliminary prevention models have been developed, but they are not yet widely applied. Patients experience limited exposure to clinicians adequately trained to address their problems and little information to guide care decisions, particularly concerning bipolar disorder. National efforts are required to restructure healthcare delivery and provider training and to immediately develop more advanced research on pathophysiology, prevention, and services delivery effectiveness.     

Use of mental health care services by Canadians with co-occurring substance dependence and mental disorders

OBJECTIVES: This study contributes to knowledge of the processes underlying help seeking by those with mental and substance use disorders by examining relationships among need, service use, and satisfaction with mental health care in a population-based sample. METHODS: Secondary data analyses were performed on responses to the 2002 Canadian Community Health Survey (N=36,984). Diagnostic algorithms classified respondents by past-year diagnostic status, including substance dependence and selected mood and anxiety disorders. Logistic regressions examined associations between diagnostic status and service use, satisfaction, and unmet need for care. RESULTS: Ten percent of Canadians and 39% of Canadians with a mental disorder or substance dependence sought services in the year preceding data collection. Although those with co-occurring substance dependence and mental disorders reported the poorest mental health and were most likely to seek care, the presence of a mental disorder, regardless of co-occurring substance dependence, contributed primarily to help seeking. Among those who sought services, the use of informal sources of care, including self-help groups, was more common among those with substance dependence. Those with co-occurring disorders reported the lowest satisfaction with care and the greatest prevalence of unmet need. CONCLUSIONS: The differential use of services, satisfaction, and unmet need across diagnostic status allowed for speculation on differing levels of disability and stigma in the help-seeking process for different types of disorders. The strong association between co-occurring disorders and unmet need for care, including a large proportion of respondents who stated they preferred to self-manage their symptoms, is particularly troubling and deserves future research attention.     

Self‐reported utilization of mental health services in the adult German population – evidence for unmet needs? Results of the DEGS1‐Mental Health Module (DEGS1‐MH)

This paper provides up‐to‐date data on service use for mental health problems and disorders among adults aged 18‐79 years in Germany derived from the Mental Health Module of the German Health Interview and Examination Survey for Adults (DEGS1‐MH; N=4483). Data are based exclusively on self‐report. Respondents were examined by clinically trained interviewers with a modified version of the Composite International Diagnostic Interview DIA‐X/M‐CIDI to assess diagnoses according to the criteria of DSM‐IV‐TR. Service use, i.e. contact to mental health care services, due to mental health problems was assessed for the past 12 months and lifetime, by type of sector and type of institution. Among respondents with a 12‐month diagnosis of a mental disorder, 23.5% of the women and 11.6% of the men reported any service use in the past 12 months. Service use depends on type of diagnosis, comorbidity and socio‐demographic characteristics. Lowest 12‐month utilization rates were found for substance use disorders (15.6%; lifetime use 37.3%), highest for psychotic disorders (40.5%; lifetime 72.1%). Further, a considerable time lap was found between disorder onset and subsequent service use among the majority of cases with anxiety and mood disorders. This paper provides self‐reported epidemiological data on mental health service use in Germany, complementing administrative statistics and the predecessor mental health module of the German Health Interview and Examination Survey (GHS‐MHS) from 1998. Despite considerable changes in the mental health field in Germany and the existence of a comprehensive mental health care system without major financial barriers, we find no indications of substantially higher utilization rates for mental disorders as compared to other comparable European countries. Further, no indications of major overall changes in utilization rates are apparent. To pinpoint areas with unmet needs, more detailed analyses of the data are needed taking into account type, frequency, and adequacy of service use and treatment of mental disorders. Appropriately matched comparisons with the GHS‐MHS are needed to identify changes in patterns of utilization and interventions by type of disorder. Copyright © 2014 John Wiley & Sons, Ltd.     

Service costs of caring for adolescents with mental illness in a rural community, 1993-2000

OBJECTIVE: Costs of treating child psychiatric disorders fall on educational, primary care, juvenile justice, and social service agencies as well as on psychiatric services. The authors estimated multiagency mental health costs by integrating service unit costs with utilization rates in an 11-county area. Using psychiatric diagnoses made independently of service use records, the authors calculated costs across agencies as well as the extent of unmet need for psychiatric care. METHOD: Annual parent and child reports were used to measure mental health care needs and units of service across 21 types of settings for the population-based Great Smoky Mountain Study sample of 1,420 adolescents from ages 13 to 16. Unit costs for services were generated from information from service providers and records. The authors calculated costs overall, costs by type of service, and costs by diagnosis. RESULTS: Average annual costs per adolescent treated were $3,146. Juvenile justice and inpatient/residential facilities accounted for well over half of the total costs. Costs for youths with two or more diagnoses were twice as much as costs of those with a single disorder. Among adolescents with service needs, 66.9% received no services. Public health insurance was associated with higher rates of specialty mental health care than either private insurance or no insurance. CONCLUSIONS: Annual costs across all services were three to four times greater than recent health insurance estimates alone. Many costs for adolescents with mental health problems were borne by agencies not designed primarily to provide psychiatric or psychological services. Only one in three adolescents needing psychiatric care received any mental health services.     

Differential Service Utilization Associated With Trauma-informed Integrated Treatment for Women With Co-occurring Disorders

Women with co-occurring mental health and substance use disorders and trauma histories vary greatly in symptom severity and use of support services. This study estimated differential effects of an integrated treatment intervention (IT) across sub-groups of women in this population on services utilization outcomes. Data from a national study were used to cluster participants by symptoms and service utilization, and then estimate the effect of IT versus usual care on 12-month service utilization for each sub-group. The intervention effect varied significantly across groups, in particular indicating relative increases in residential treatment utilization associated with IT among women with predominating trauma and substance abuse symptoms. Understanding how IT influences service utilization for different groups of women in this population with complex needs is an important step toward achieving an optimal balance between need for treatment and service utilization, which can ultimately improve outcomes and conserve resources.     

Child and adolescent mental health in South Africa

Mental health problems in childhood and adolescence pose a major threat to public health. Epidemiological studies in high, middle and low income countries indicate that approximately one in five children and adolescents suffer from a mental disorder. In many instances these persist into adulthood. In South Africa, HIV infection, substance use, and exposure to violence increase vulnerability to mental disorders. Child and adolescent mental health services play a key role in reducing the burden of mental disorders in childhood and later in adulthood. This paper focuses on service needs for children and adolescents in South Africa. It commences with a discussion of the prevalence of child and adolescent psychiatric disorders after which the legal and policy context of child and adolescent psychiatric services is described. A framework for child and adolescent mental health service provision is presented, following which steps for reducing the extent of unmet service need are considered. The paper concludes with a call to scale up child and adolescent mental health services in South Africa, based on the stark realities of unmet need and the constitutional rights of children and adolescents to appropriate mental health care.     

Clinical characteristics of youths with substance use problems and implications for residential treatment

OBJECTIVE: Despite high rates of dual diagnosis among children and adolescents and evidence that adults with coexisting substance use disorders require specialized services, many children are placed in residential settings and are offered uniform service packages regardless of their individual clinical profiles. The authors examined the rate of substance use problems in a sample of children and adolescents with severe emotional or behavioral disturbances who were in residential treatment. Differences in clinical characteristics and placement outcomes between children with and without coexisting substance use disorders were evaluated. METHODS: This retrospective study analyzed clinical data obtained by chart review using the Child Severity of Psychiatric Illness, a rating scale for symptom severity. The study subjects were 564 children and adolescents in residential treatment and state custody in Florida and Illinois who had serious emotional or behavioral disturbances. RESULTS: Twenty-six percent of boys and 37 percent of girls had substance use problems in addition to serious emotional or behavioral disturbances. Residents with co-occurring substance use disorders were significantly more likely than those with serious emotional or behavioral disturbances only to be at risk for suicide, elopement from residential placement, delinquent behavior, and institutional discharge placement. CONCLUSIONS: Children and adolescents with coexisting substance use problems require individualized service packages to address their greater need for supervision and higher rate of risk behaviors and to facilitate community discharge placements.     

Factors associated with adolescent mental health service need and utilization

OBJECTIVE: To determine the association of parent, family, and adolescent variables with adolescent mental health service need and utilization. METHOD: Correlates of adolescent mental health service utilization, self-perceived need and unmet need were investigated in a general population sample of 1,120 Dutch adolescents aged 11 to 18 years (78% response rate). RESULTS: 3.1% of the sample had been referred for mental health services within the preceding year, and 3.8% reported unmet need. 7.7% of adolescents at risk for psychopathology, and 17.8% of those indicating a need for help, had been referred. Family stress and adolescent's self-reported problems were most strongly associated with service need and utilization. Internalizing problems, female gender, and low education level were associated with self-perceived unmet need. Adolescent ethnicity and competence in activities and school were associated with service use, but did not influence service need, while the opposite effect was found for adolescent age and parental psychopathology. CONCLUSION: In designing intervention programs aimed at increasing adolescent mental health service use, distinctions should be made between efforts focused at adolescents not recognizing their problems, and those with unmet need.     

A national survey of care for persons with co-occurring mental and substance use disorders

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.     

Care Integration in the Patient Protection and Affordable Care Act: Implications for Behavioral Health

Individuals with co-occurring serious mental illness and substance use disorders experience a highly fragmented system of care, contributing to poor health outcomes and elevated levels of unmet treatment needs. Several elements in the health care reform law may address these issues by enhancing the integration of physical and behavioral health care systems. The purpose of this paper is to analyze these elements, which fall into three domains: increasing access, restructuring financing and reimbursement mechanisms, and enhancing infrastructure. We conclude with a consideration of the implementation challenges that lie ahead.     

Needs for mental health care and service provision in single homeless people

Background: Specific problems in sampling methodology, case-finding strategies and a standardised needs assessment in mentally ill homeless people have contributed to their being neglected as a mental health care clientele. Method: We assessed a representative sample of homeless people (n=102) in the highly industrialised city of Mannheim (Germany) regarding their prevalence of mental disorders (using the SCID) and their needs for mental health care (using the NCA). Results: We found high prevalences, with 68.6 % of all assessed homeless persons having a current mental disorder. Thus, needs for mental health care were very common, with unmet needs predominating in all problem areas, which was supported by a very weak service utilization. Thus, even in a region with a comprehensive community mental health care network, like the study area, mentally ill homeless people are widely under-provided. Conclusions: Results suggest that the traditional shelter system for homeless people carries most of the mental health care burden for their clientele and must be supported by adequate interventions from community-based mental health care services. A closer connection of both sectors and a better co-ordination of the care offers seems to be a prerequisite for helping to reduce unmet mental health care needs in this specific high-risk group. Accepted: 2 January 2001     

Needs for care and effectiveness of mental health care provision for schizophrenic patients in two European regions: a comparison between Granada (Spain) and Mannheim (Germany)

OBJECTIVE: The aims of this study were to develop an indicator for comparing the effectiveness of community mental health care across different areas, and to compare the effectiveness of care for schizophrenic patients in two European regions. METHOD: In a long-term follow-up, service utilization, needs for care and met needs of schizophrenic patients were assessed. An indicator of effectiveness of care was calculated for each region and compared. RESULTS: Patients in Mannheim received much more intervention in all types of mental health care. Despite differing utilization patterns, the indicator of effectiveness of care revealed no differences in the area of symptoms and behaviour problems between the two regions, while significant differences in the area of skills and abilities of patients were detected. CONCLUSION: We succeeded in defining a measure that describes effectiveness of mental health care in terms of the long-term relationship between needs and unmet needs of patients. Our results contribute to an evidence-based discussion of the improvement of community mental health care networks.     

Integrated substance use and mental health treatment for adolescents: aligning organizational and financial incentives

The high prevalence of the dual diagnosis of mental and substance use disorders (SUD) has been increasingly documented for both adolescents and adults (Crowley and Riggs 1995; Kandel et al. 1999; Whitmore et al. 1997). For more than a decade, the National Institute of Drug Abuse (NIDA) has included integrated treatment of comorbid psychiatric disorders as one of nine core treatment principles (National Institute on Drug Abuse 1999). Despite empirically supported practice guidelines, implementation of integrated treatment has been slow (New Freedom Commission on Mental Health 2003; U.S. Department of Health and Human Services 1999). In response to the growing call for integrated treatments and systems of care, this paper: (1) identifies systemic and economic barriers that have impeded widespread implementation of integrated care for adolescents with co-occurring SUD, specifically the supply of treatment providers, shifting priorities of gatekeepers to specialty care, and financing streams; and (2) describes possibilities for aligning economic incentives in order to facilitate the dissemination and implementation of integrated care for adolescents with co-occurring SUD.     

Clinical Characteristics and Service Utilization Patterns of Clients with Schizophrenia-Spectrum Disorders in Public Residential Detoxification Settings

Little is known about the treatment needs of clients found in residential detoxification programs who have comorbid schizophrenia-spectrum and substance use disorders. This study (N = 166) compares the service use patterns of comorbid detoxification clients with schizophrenia-spectrum disorders (CDT-S) to two other client groups: (1) comorbid detoxification clients with other mental health disorders (CDT-O), and (2) comorbid clients in residential mental health facilities with schizophrenia-spectrum disorders (CMH-S). Results show that CDT-S clients were much less likely to receive subsequent mental health treatment than CMH-S clients. Findings indicate that detoxification programs may be important settings in which to identify clients with schizophrenia who have unmet mental health treatment needs.Jennifer Alvidrez and Barbara E. Havassy are affiliated with the Department of Psychiatry, University of California, San Francisco, USA.     

American Indians with HIV/AIDS: health and social service needs, barriers to care, and satisfaction with services among a Western tribe

This study investigated the health care and social service needs, barriers to care and satisfaction with services among American Indians with HIV/AIDS in a western tribe. Individual interviews were conducted with 28 respondents, which constituted nearly the entire population obtaining HIV/AIDS medical services from the IHS in the target area. The survey found that expressed need for services in this frontier rural area were lower than urban counterparts, but that access to needed services was lower. Common unmet medical needs include mental health services, eye and dental care, traditional Native medicine, and substance abuse treatment. Common unmet social service needs include housing assistance, help obtaining food and clothing, and transportation. Limited access to essential services impedes the ability of American Indians with HIV/AIDS to maintain effective medical regimens.     

Rates and predictors of aftercare services among formerly hospitalized adolescents: a prospective naturalistic study

OBJECTIVE: To examine rates and predictors of aftercare use, lengths of service use, and predictors of the duration of aftercare service use among 180 adolescents monitored for up to 8.1 years after discharge from an inpatient psychiatry unit. METHOD: Drawing upon the Anderson-Newman model of service use, severity of illness, enabling, and predisposing factors assessed during the hospitalization were examined as potential predictors of service use. Information about outpatient mental health specialty services after hospitalization was assessed repeatedly and verified with treatment records. RESULTS: Seventy-three percent of adolescents received aftercare within the first month after discharge, and 92% eventually received outpatient services. Fifty-seven percent of adolescents remained in treatment 6 months after initiation of services. Psychiatric comorbidity, prior service use, and presence of a biological parent or grandparent in the home were related to initial service use. Psychiatric comorbidity and history of repeated suicide attempts were related to longer duration, and older age and minority group status were related to shorter duration of aftercare service use. CONCLUSIONS: Most adolescents receive aftercare services, but there are certain groups that are relatively less likely to access or remain in services. Interventions to decrease the barriers to care in such groups may be beneficial.     

Unmet need for mental health care among U.S. children: variation by ethnicity and insurance status

OBJECTIVE: Policy discussions regarding the mental health needs of children and adolescents emphasize a lack of use of mental health services among youth, but few national estimates are available. The authors use three national data sets and examine ethnic disparities in unmet need (defined as having a need for mental health evaluation but not using any services in a 1-year period) to provide such estimates. METHOD: The authors conducted secondary data analyses in three nationally representative household surveys fielded in 1996-1998: the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey. They determined rates of mental health service use by children and adolescents 3-17 years of age and differences by ethnicity and insurance status. Among the children defined as in need of mental health services, defined by an estimator of mental health problems (selected items from the Child Behavior Checklist), they examined the association of unmet need with ethnicity and insurance status. RESULTS: In a 12-month period, 2%-3% of children 3-5 years old and 6%-9% of children and adolescents 6-17 years old used mental health services. Of children and adolescents 6-17 years old who were defined as needing mental health services, nearly 80% did not receive mental health care. Controlling for other factors, the authors determined that the rate of unmet need was greater among Latino than white children and among uninsured than publicly insured children. CONCLUSIONS: These findings reveal that most children who need a mental health evaluation do not receive services and that Latinos and the uninsured have especially high rates of unmet need relative to other children. Rates of use of mental health services are extremely low among preschool children. Research clarifying the reasons for high rates of unmet need in specific groups can help inform policy and clinical programs.     

Aftercare of depressed inpatients

Background: In contrast to acute treatment, delivery of aftercare to depressed patients has not been well studied. Poor care may contribute to poor outcomes for treated depression. Methods: One hundred and two patients discharged from hospital with unipolar depression were followed up 18 months later and were interviewed in detail regarding aftercare and treatment received. Unmet needs were assessed on the community version of the MRC Needs for Care Assessment. Results: In the first month after discharge approximately 70 % of subjects received contacts with mental health services and in the first 3 months over 80 % received at least one contact. About 40 % were in contact with mental health services at 18 months. Needs assessment found comparatively low unmet needs, reaching highest levels (around 25 % in any 6-month period) for medication. Two-thirds of unmet needs for medication and psychotherapy were due to patient refusal or non-compliance. Aftercare levels were higher in those with more previous admissions and were unrelated to presence of personality disorder. Conclusions: There were some deficiencies in service aftercare for depressed patients in a British NHS setting, although unmet need was not high. Some aftercare failures reflect patient reluctance to receive further treatment, representing a challenge to overcome in patients entitled to autonomous choices. Accepted: 27 September 2002 Correspondence to R. Ramana