Access to Mental Health Services and Health Sector Social Capital

Mental health services are underused relative to mental illness rates. We hypothesized a positive correlation between use of mental health services and community-level health care social capital. Community Tracking Study data from 43 cities (N=43,278), merged with the National Profile of Local Health Departments and other sources, show that use of mental health services was greater when public health districts collaborated with managed care organizations and other community groups, independent of individual predictors and health care system variables. Use was also positively associated with community levels of public insurance coverage and with direct public health provision of behavioral health care services. Research is needed to understand the mechanisms by which social capital may improve access to mental health services.     

Commentary: Hispanic Access to Health/Mental Health Services

Currently, the Hispanic population of the United States is growing very rapidly. Despite the significance of this growth and the fact that it is expected that Hispanics will be soon the largest ethnic minority group in this country, the access to health/mental health care for the Hispanic population is rather limited. Many factors are currently affecting the Hispanics' access to health/mental health care services. Among them, cultural and language barriers, insufficient numbers of Hispanic manpower in the health care professions, low educational and socioeconomic levels, the high number of uninsured Hispanics, and ethnic and racial prejudices and discrimination. In this commentary, I address the factors that interfere with the Hispanics' access to health/mental health care, and advance recommendations geared to alleviate and/or resolve this critical problem.     

Telepsychiatry and e-Mental Health Services: Potential for Improving Access to Mental Health Care

Reforming mental health care is a focus of many ongoing initiatives in the United States, both at the national and state levels. Access to adequate mental health care services is one of the identified problems. Telepsychiatry and e-mental health services could improve access to mental health care in rural, remote and underserved areas. The authors discuss the required technology, common applications and barriers associated with the implementation of telepsychiatry and e-mental health services.     

Child Mental Health Services in the New South Africa

Health departments in the new South Africa are undergoing major restructuring and, in some cases, severe financial cutbacks as new policies attempt to redress the inequities of the past. A district system is being phased in, with a shift in funding from academic hospitals to secondary and primary level care. The process is being undermined by the current recession, which also affects Welfare and Education facilities, and by widespread poverty, violence, and other adverse conditions. Child mental health services are discussed in the light of current human resources, epidemiological data, the effects of violence and cultural issues, together with some reflections on their future.     

Youths' Access to Mental Health Services: The Role of Providers' Training,Resource Connectivity,and Assessment of Need

This paper posits that providers with training in and knowledge of mental health resources are more likely to recognize youths' mental health problems, and provide youths with services. In 1994 and 1996, we interviewed 792 adolescents who were involved with St. Louis public health, juvenile justice, child welfare, or education service sectors. Two hundred eighty-two youths had received some services, listing 533 providers. We could identify 364 of those providers, and 61% (222) responded concerning service need, service use, and provider knowledge and behavior. Structural equation models demonstrate that provider assessment of youths' mental health problems is the largest and provider knowledge of service resources the second largest determinant of service provision. Youths' self-reported mental health is not positively associated with increased services and is only minimally associated with provider assessment of their problems. Training (both professional and inservice) contributes to higher assessments of youths' problems and greater resource knowledge, which is associated with increased service provision. Providers from the mental health and child welfare sectors have more professional training in mental health and are more likely to receive inservice training. Inservice training should be offered to all who work with youths.     

Stigmatizing Attitudes About Mental Illness and Allocation of Resources to Mental Health Services

This study tests a social psychological model (Skitka & Tetlock, 1992). Journal of Experimental Social Psychology, 28, 491-522; [1993]. Journal of Personality & Social Psychology, 65, 1205-1223 stating that policy maker decisions regarding the allocation of resources to mental health services are influenced by their attitudes towards people with mental illness and treatment efficacy. Fifty four individuals participated in a larger study of education about mental health stigma. Participants completed various measures of resource allocation preferences for mandated treatment and rehabilitation services, attributions about people with mental illness, and factors that influence allocation preferences including perceived treatment efficacy. Results showed significant attitudinal correlates with resource allocation preferences for mandated treatment, but no correlates to rehabilitation services. In particular, people who pity people with mental illness as well as those that endorse coercive and segregated treatments, were more likely to rate resource allocation to mandated care as important. Perceived treatment efficacy was also positively associated with resource allocation preferences for mandated treatment. A separate behavioral measure that involved donating money to NAMI was found to be inversely associated with blaming people for their mental illness and not being willing to help them. Implications of these findings on strategies that seek to increase resources for mental health programs are discussed.     

Consumer and Family Views on Evidence-Based Practices and Adult Mental Health Services

Evidence-based practice (EBP) is an important construct in mental health services. Though much has been written about them, there is little in the literature that fully explores consumers’ and family members’ views regarding EBPs. Using a focus group methodology, this study asked the question “What are consumers’ and family member’s views of EBPs within the larger context of their mental health service needs and their experiences with the mental health service system?” Results indicate that consumers and families have limited knowledge of EBPs, are generally supportive of EBPs, but have questions and concerns that are grounded in systemic and contextual considerations.     

Child Characteristics Influencing Referral to Mental Health Services

This study explored whether certain child characteristics (age, type of problem presented, and gender) influenced the referral decisions of parents, general practitioners, and child psychologists. These three groups were taken as key gatekeepers in controlling access to mental health services. Results suggested that age of child and type of problem significantly affected the subject's responses whilst sex of child did not. Psychologically disturbed 10-year olds may be more likely to reach mental health services than psychologically disturbed 3-year olds, and children who showed their disturbance in terms of conduct disorder may be more likely to arouse concern than those who present with emotional disturbance.     

Barriers to Providing Effective Mental Health Services to American Indians

Like most indigenous populations throughout the world who have undergone innumerable cultural changes, the mental health care needs of American Indians are great. Some surveys conducted by the Indian Health Service show high rates of suicide, mortality, depression and substance abuse. Little is known about effective mental health care among American Indians due, in part, to the lack of culturally appropriate models of mental health in American Indians. This article presents a cultural framework in order to understand the mental health care needs of American Indians and discusses barriers to providing effective mental health services to American Indians.     

Barriers to Providing Effective Mental Health Services to Asian Americans

Using the research framework recommended by L. Rogler, R. Malgady, and D. Rodriguez (1989), the current paper examines the barriers to providing effective mental health services to Asian Americans. Beginning with the recognition that Asian Americans consists of numerous heterogeneous subgroups, the issue of the stereotype of Asian Americans as the model minority was also discussed. The primary focus of the paper is on Stages 2, 3, and 4 within the Rogler et al. (1989) model and the identification and discussion of cultural factors that hinder the delivery of mental health services to Asian Americans. The paper is therefore organized into these three sections: (a) help-seeking or mental health service utilization, (b) evaluation of mental health problems, and (c) psychotherapeutic services. In each of the sections, not only are the barriers to delivery of effective mental health services discussed but so are the research and methodological problems as well as some directions for future research. This critical review of the literature has been prepared with the goal of serving as a blueprint for us to pursue rigorous but relevant research to identify and reduce these cultural barriers to providing effective mental health services to Asian Americans.     

Priority Issues in Latino Mental Health Services Research

This paper identifies issues and trends affecting the quality and comprehensiveness of Latino mental health research and services. These issues include current patterns of need and services use, rapid expansion of the Latino population, extraordinary rates of uninsured, social and language barriers to care, transformation in treatment science and technology, and the sheer complexity and rapid changes in the delivery system. Progress in the field requires coordination and investments from both public and private sectors. Scientific journals should provide assistance for creating a high quality knowledge base and rapidly disseminating this information to students, practitioners, and policy makers. Vigorous activity is needed to (1) augment the supply of people entering the pipeline for researcher and practitioner training, and (2) support research in priority areas such as outcome studies for diverse treatments and different sectors of care, cultural competence, treatment models for youth and aging populations, quality of care, and barriers to mental health care.     

Use of Mental Health Services by Youths in Public Sectors of Care

The present paper examined the lifetime rates of mental health service use in a representative sample of youths identified as receiving services in at least one sector of care in a publicly funded service system of a large, metropolitan area. Service use was examined in relation to age, gender, mental health diagnostic status, and service sector involvement. Participants were 1706 youths ages 6-17 years who were active in at least one of the following service sectors: alcohol and drug services, child welfare, juvenile justice, mental health, and special education services for serious emotional disturbance. Structured service use and diagnostic interviews were administered to youths and their caregivers. High lifetime rates of mental health service use were found. Eighty-seven percent of the sample used at least one outpatient service, 45% used at least one inpatient service, and 71% reported use of a school-based service. Youths involved with the mental health and special education sectors had the highest rates of service use. In contrast, youths enumerated from the juvenile justice system tended to have the lowest rates of use. Additional research is needed to refine our understanding of the factors associated with the observed patterns of service use.     

CONNECT: A Measure of Continuity of Care in Mental Health Services

This paper introduces a measure of continuity of care (CONNECT) developed for mental health services research. CONNECT addresses qualities of interpersonal interaction in service-user/practitioner relationships through 13 scales and one single-item indicator. The scales are grouped into five domains: knowledge, flexibility, availability, coordination, and transitions. Domains were derived from ethnographic data. Service users rate responses to items using 5-point scales. The measure is administered in interview format. CONNECT was developed for use with persons who have serious mental illness. Preliminary testing included cognitive interviews and two pilot studies. The results of a field test in which 400 persons with serious mental illness completed CONNECT indicate that the measure is easily administered and produces well-distributed responses. Five scales meet the .80 criterion for internal-consistency reliability for group-level research. Estimates of 2-week test-retest reliability indicate fair- to-good agreement. A broad initial validation strategy including known groups and convergent validity assessments produced results that will inform and focus future efforts. Next steps in the measure development process are discussed.     

Correlates of Adolescents' Satisfaction with Mental Health Services

While there has been increased attention to consumers' satisfaction with mental health services as an indicator of quality of care, little is known about the construct of consumer satisfaction, especially for youth. The goal of this study was to examine potential correlates of adolescents' satisfaction with mental health services. One hundred eighty adolescents who had received out-patient mental health services completed a multidimensional satisfaction scale and measures of behavior problems, attitudes and expectations about treatment, perceived choice/motivation in seeking treatment, and service use history. Results indicate that the strongest unique correlates of satisfaction are severity of behavior problems, positive expectations about services, and perceived choice in seeking services. Satisfaction with services was also associated with service site, length of time in treatment, and reason for entering treatment. Demographic variables were not related to satisfaction. A discussion of the appropriateness of using satisfaction as an indicator of quality of care is included.     

The Mental Health of Children Exposed to Maternal Mental Illness and Homelessness

In recent years a number of reports have documented an increase in the number of homeless families in the US. Using a sample of 195 mothers who were veterans of the US armed forces we assessed the association of maternal homelessness and clinical status, with measures of children’s mental health, school enrolment and attendance. Although maternal homelessness had no significant association with children’s reported emotional problems it had a profound effect on school enrollment and attendance. Mothers’ mental health status, history of incarceration and cumulative history of trauma, as well as children’s exposure to trauma and their self-esteem were the factors most strongly associated with measures of children’s emotional problems. The study suggests that preventive interventions are needed to minimize the effects of exposure to trauma, both in the community and at home, as well as family interventions to address both the mother’s and child’s emotional and physical needs. A longitudinal study is needed to understand better the association between residential instability and children’s mental health.Ilan Harpaz-Rotem, Ph.D., Robert A. Rosenheck, M.D. and Rani Desai, Ph.D, MPH are affiliated with the Department of Psychiatry, Yale University School of Medicine, West Haven, CT.     

Utilization of Public Mental Health Services by Adults with Serious Mental Illness

Public mental health (MH) services were examined for non-elderly adults with serious mental illness (SMI) using a database combining information from Medicaid, MH, and substance abuse agencies in three states. These data show that between 23% and 39% of those with SMI received MH services only through Medicaid. Relative use of community versus state hospitals for delivery of psychiatric inpatient care varied across the three states. However, state hospitals accounted for a large proportion of total inpatient days, due to high mean annual days of care. In two states, Medicaid paid for fewer psychiatric inpatient days than expected.     

Methodological Challenges in Assessing Children's Mental Health Services Utilization

This paper describes the reliability and validity of the service assessment for children and adolescents (SACA) for use among Spanish-speaking respondents. The test-retest reliability of the instrument was assessed in a randomly selected clinical sample of 146 Puerto Rican children and adolescents aged 4–17. Both parents and children were administered the SACA twice by independent interviewers over an average 12-day follow-up period. The accuracy of parental and youth self-reports was assessed by comparing these reports to information obtained from medical records. The results showed that parents and children (aged 11–17) were able to report with fair to moderate reliability any last year use of mental health services, any outpatient mental health services, and school services. Residential and hospitalization services were reported by both informants with substantial test-retest reliability. Slight or no test-retest reliability was obtained for parent and child on the use of the specific type of mental health professionals, as well as parental reports of several treatment modalities. Substantial sensitivity of the SACA was obtained when comparing medical records to parental and child reports to lifetime use of any service and outpatient mental health service. Moderate sensitivity was obtained for last year use of mental health services for both parent and child informants.     

Organizational and Individual Factors Affecting Consumer Outcomes of Care in Mental Health Services

The impact of organizational and individual factors on outcomes of care were assessed for 424 adult consumers with chronic mental illness who were receiving services from one of 14 Community Mental Health Organizations (CMHOs) in Colorado over a 30-month period, as part of a larger statewide evaluation of the impact of Medicaid capitation on mental health services. Data on organizational culture and climate were aggregated from surveys of staff and administrators conducted within CMHOs over a two-year period corresponding to the collection of consumer outcome and service utilization data. Growth curve analyses were conducted on consumer perceptions of physical and mental health, and on quality of life (QOL). Analyses indicated a significant cross-level effect of organizational culture and climate on improvements in consumer perceptions of physical and mental health, but not on a “quasi-objective” index of QOL. Individual characteristics, such as age, diagnosis, gender, and ethnicity, were significant predictors of outcomes. Being older, female, an ethnic minority, and having a diagnosis of schizophrenia all predicted poorer outcomes among consumers. These findings are discussed in terms of their implications for policy and future research.