Unmet Mental Health Care Needs for Children with Special Health Care Needs Stratified by Socioeconomic Status

Background:  The purpose of this research study was to identify factors that affect mental health care for children with special health care needs (CSHCN) and to identify how these factors vary among different socioeconomic levels.
Methods:  Data were obtained from the National Survey of Children with Special Health Care Needs, 2000–2002. The analysis examined the relationships of demographic characteristics, geographical location of household, severity of condition, and social factors on unmet need for mental health care. Multiple logistic regression models were constructed for four socioeconomic status (SES) levels defined by the federal poverty level (FPL): <133%; 133–199%; 200–299%; ≥300%. Standardised regression coefficients were calculated to compare among SES strata.
Results:  There were 38,866 CSHCNs represented in the survey with 9,639 needing mental health care in the past 12 months. The household income distribution was 22% below the 133% FPL, 15% between 133–199% FPL, 18% between 200–299% FPL, and 45% at or above 300% FPL. Black race, ethnicity, insurance type/status, geographical location of household, and number of kids in the household were significant in the <133% of FPL stratum for predicting having received all needed mental health care in the last 12 months. Age and geographical location of household were significant in the 133–199% of FPL stratum. Maternal education was significant in the 200–299% of FPL stratum. Severity of condition, other race, and insurance type/status were significant in the ≥300% of FPL stratum.
Conclusions:  Factors affecting unmet needs for mental health care differed by socioeconomic status. Future research should explore a more in-depth picture of the CSHCN population that includes stratification by income groups to better understand and serve this population.     

Health reform and the scope of benefits for mental health and substance use disorder services

The Patient Protection and Affordable Care Act will expand insurance coverage to millions of Americans with mental disorders. One particularly important implementation issue is the scope of mental health and substance abuse services under expanded health insurance coverage. This article examines current public and commercial insurance coverage of the range of services used by individuals with mental illnesses and substance use disorders and assesses the implications of newly mandated standards for benefit packages offered by public and private plans. The authors note that many services needed by individuals with mental or substance use disorders fall outside the scope of benefits currently covered by a typical private insurance plan. Compared with other insurers, Medicaid currently covers a broader range of behavioral health services; however, individuals moving into Medicaid under new eligibility pathways will receive "benchmark" or "benchmark-equivalent" coverage rather than full Medicaid benefits. If behavioral health benefits are set at those currently available in typical private plans or in benchmark coverage, some newly insured individuals with mental illnesses or substance use disorders who are covered by private plans or Medicaid expansions are still likely to face gaps in covered services. Policy makers have several options for addressing these likely gaps in coverage, including requiring states to maintain coverage of some support services, including certain behavioral health services in the "essential benefits package," and expanding eligibility for full Medicaid benefits.     

The Mental Health of Adolescents Residing in Court-Ordered Foster Care: Findings from a Population Survey

The mental health of a representative sample of 230 adolescents residing in foster care in New South Wales, Australia, was estimated in a state-wide epidemiological survey from carer-report responses on the Child Behavior Checklist (CBCL) and the Assessment Checklist for Adolescents (ACA). Rates of CBCL total problems, externalizing and internalizing scores above the borderline range cut-points were 49, 44 and 29% respectively, representing a relative risk of 3.8, 3.7 and 2.7 respectively in comparison to Australian children at large. These rates are 10–14% lower than that previously estimated for pre-adolescent Australian children in foster care. Whereas older age is associated with poorer mental health among pre-adolescent children in foster care, the present study findings suggest that this effect does not extend into adolescence. Around half of adolescents residing in foster care have mental health difficulties requiring referral to treatment services, including attachment- and trauma-related difficulties that are uncommon among clinic-referred children at large.     

The political evolution of mental health parity

This article traces the evolution of the mental health parity debate in American politics, with a focus on how interest groups and politicians have attempted to influence perceptions about treatment effectiveness and the cost of benefit expansion. When parity laws are in place, they require health plans operating in the private health insurance market to provide an equivalent level of coverage for mental health and general medical care. Business and insurance industry groups oppose parity due to cost concerns. The mental health community has framed parity as an antidiscrimination measure that would achieve greater insurance equity across disease groups. The role of personal experience with mental illness among lawmakers and others in framing the parity debate is also considered.     

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.     

The Relationship Between Perceived Unmet Mental Health Care Needs and Suicidal Ideation and Attempt

This study utilizes data from the National Survey of Drug Use and Health (NSDUH) to analyze the relationship between perceived unmet mental health care needs and suicidal ideation and attempt. Estimates from multivariable logistic regression models suggest that individuals who report perceived unmet mental health care needs have higher probability of experiencing suicidal ideation and attempt. Perceived unmet mental health care need has an important association with suicidal ideation and attempt, and efforts aimed at improving access to care are needed to address this issue.     

Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario

OBJECTIVE: The authors interviewed individuals treated for self-described mental health problems in the preceding year to examine patterns and predictors associated with dropping out of treatment. METHOD: Subjects were drawn from respondents to community epidemiological surveys carried out in representative samples of the United States and Ontario populations. Dropouts were those who had left mental health treatment during the prior year for reasons other than symptom improvement. The surveys also assessed potential dropout correlates: sociodemographic characteristics, attitudes about mental health care, disorder type, provider type, and treatment received. RESULTS: The proportion of dropouts did not significantly differ between the United States (19.2%) and Ontario (16.9%), nor did the effects of the predictors differ significantly between the two samples. Sociodemographic characteristics associated with treatment dropout included low income, young age, and, in the United States, lacking insurance coverage for mental health treatment. Patient attitudes associated with dropout included viewing mental health treatment as relatively ineffective and embarrassment about seeing a mental health provider. Respondents who received both medication and talk therapy were less likely to drop out than those who received single-modality treatments. CONCLUSIONS: Mental health treatment dropout is a serious problem, especially among patients who have low income, are young, lack insurance, are offered only single-modality treatments, and have negative attitudes about mental health care. Cost-effective interventions targeting these groups are needed to increase the proportion of patients who complete an adequate course of treatment.     

Regulating a health insurance exchange: implications for individuals with mental illness

Under the newly enacted health reform law, millions of lower- and middle-income Americans will purchase individual or family health insurance through state-based markets for private health insurance called insurance "exchanges," which consolidate and regulate the market for individual and small-group health insurance. The authors consider options for structuring choice and pricing of health insurance in an exchange from the perspective of efficiently and fairly serving persons with mental illness. Exchanges are intended to foster choice and competition. However, certain features-open enrollment, individual choice, and imperfect risk adjusters-create incentives for "adverse selection," especially in providing coverage for persons with mental illness, who have higher overall health care costs. The authors review the experience of persons with mental illness in insurance markets similar to the exchanges, such as the Massachusetts Connector and the Federal Employees Health Benefit Program, and note that competition among health plans for enrollees who are "good risks" can undermine coverage and efficiency. They review the possible approaches for contending with selection-related incentives, such as carving out all or part of mental health benefits, providing reinsurance for some mental health care costs, or their preferred option, running the exchange in the same way that an employer runs its employee benefits and addressing selection and cost control issues by choice of contractor. The authors also consider approaches an exchange could use to promote effective consumer choice, such as passive and active roles for the exchange authority. Regulation will be necessary to establish a foundation for success of the exchanges.     

Detrimental Effects of COVID-19 Measures on Mental Health and Social-Economic Disparities

The COVID-19 pandemic has struck nations worldwide, pushing worldwide health and socioeconomic systems to extreme limits. Various factors, such as drastic alterations in public environments, prolonged quarantine, revenue loss, and anxiety of disease contraction, have caused mental turmoil. Although there was a need to cope with an excess of psychological strain among the public, post-COVID patients, and those with a previously diagnosed psychiatric condition, mental health programs faced a substantial decline in services, mirroring the dramatic rise in psychological issues. Interestingly, certain coping strategies play protective or deleterious effects on mental health outcomes. Moreover, social media exposure has played a double-edged role in the mental health of the public during the pandemic, leaving grounds for further debates. Protean cultural themes have taken center stage in the discussion on social resilience and compliance to COVID-19 measures, driving their impact through certain work ethics, social capital, and public attitudes in different societies. On the other hand, exceedingly rising poverty rates cemented the deleterious economic impact of the pandemic. Attention has been called to the racial implications of the pandemic, driving millions of individuals with low socioeconomic position (SEP) and belonging to minority groups out of the paid workforce. Interestingly, we turn attention to an array of elements implicated in this dramatic effect, such as public transport, living arrangements, and health insurance coverage among these vulnerable groups. We attempt to address the mechanisms COVID-19 channeled its mental health and socioeconomic impacts by explaining the risk factors and pave the way for stronger crisis management in the future by evaluating the socioeconomic and psychological effects in stark detail.     

Use of outpatient mental health services by a general population with health insurance coverage

Characteristics of use of mental health services by 4,254 persons enrolled in the Rand Health Insurance Study were analyzed in an attempt to predict patterns of use by a general population with assigned insurance coverage. Families in the study, whose members ranged in age from birth through 62 years, were randomly assigned to one of 14 insurance plans covering a wide variety of services by all licensed provider groups. During a one-year period less than 4 percent of the enrollees visited a mental health specialist, and only 7.1 percent saw any provider for mental health care. About half of those receiving outpatient mental health care visited general medical providers only. Annual outpatient mental health expenses per enrollee were about $25 (1983 dollars). The authors compare their findings with those of other studies and discuss their implications for insurance coverage of mental health services.     

Prevalence and Predictors of Limited Literacy in Public Mental Health Care

Literacy is an important predictor of health care utilization and outcomes. We examine literacy among people seeking care in a state funded mental health clinic (Site 1) and a safety-net hospital clinic (Site 2). Limited literacy was defined as literacy at or below the 8th grade level. At Site 1, 53% of participants had limited reading literacy and 78% had limited aural literacy. At Site 2, 72% had limited reading and 90% had limited aural literacy. Regression analyses examined associations among limited literacy and psychiatric, neurocognitive and sociodemographic characteristics. Few associations among psychiatric and neurocognitive factors, and literacy were found. At Site 2, black and “other” race participants had higher odds for limited literacy compared to white participants suggesting that limited literacy may be an under-examined mechanism in understanding racial disparities in mental health. Work is needed to understand the relationships among literacy, mental health and mental health care.

     

Unmet Need for Mental Health Care in Schizophrenia: An Overview of Literature and New Data From a First-Admission Study

We present an overview of the literature on the patterns of mental health service use and the unmet need for care in individuals with schizophrenia with a focus on studies in the United States. We also present new data on the longitudinal course of treatments from a study of first-admission patients with schizophrenia. In epidemiological surveys, approximately 40% of the respondents with schizophrenia report that they have not received any mental health treatments in the preceding 6–12 months. Clinical epidemiological studies also find that many patients virtually drop out of treatment after their index contact with services and receive little mental health care in subsequent years. Clinical studies of patients in routine treatment settings indicate that the treatment patterns of these patients often fall short of the benchmarks set by evidence-based practice guidelines, while at least half of these patients continue to experience significant symptoms. The divergence from the guidelines is more pronounced with regard to psychosocial than medication treatments and in outpatient than in inpatient settings. The expansion of managed care has led to further reduction in the use of psychosocial treatments and, in some settings, continuity of care. In conclusion, we found a substantial level of unmet need for care among individuals with schizophrenia both at community level and in treatment settings. More than half of the individuals with this often chronic and disabling condition receive either no treatment or suboptimal treatment. Recovery in this patient population cannot be fully achieved without enhancing access to services and improving the quality of available services. The recent expansion of managed care has made this goal more difficult to achieve.     

Serious Psychological Distress and Diabetes: A Review of the Literature

With the development of a measure of serious psychological distress (SPD) in 2002, more attention is being paid to the association of SPD with diabetes outcomes and processes of care. We review the literature on the relationship between SPD and diabetes processes of care and outcomes, as well as the literature on the relationship between specific mental health diagnoses and diabetes processes of care and outcomes during the 2010 to 2011 period. There is an extensive literature on the association of mental health diagnoses with diabetes outcomes, especially for depression. Because the Kessler scale measures a much broader range of mental health issues than any specific DSM-IV/Structured Clinical Interview for DSM Disorders diagnosis and is designed to assess SPD at the population level, additional research needs to be conducted both in clinical settings and using large administrative datasets to examine the association between SPD and diabetes outcomes and processes of care.     

The association between serious psychological distress and emergency department utilization among young adults in the USA

Purpose

Psychological problems could lead to several adverse health outcomes and were strongly correlated with cigarette smoking and alcohol consumption. In addition, patients treated in EDs were vulnerable to psychological problems. We therefore examined the population-level association between serious psychological distress (SPD) and emergency department (ED) use among young adults in the USA. We also studied the additive effects of SPD, cigarette smoking, and alcohol consumption on the ED presentation.

Methods

The study sample contains 16,873 individuals, using data from the National Health Interview Survey, from 2004 to 2006. Bivariate analyses with chi-square tests and logistic regression analyses are performed.

Results

Young adults having SPD were 2.05 times more likely to go to an ED. People having SPD and being a current smoker were 2.52 times more likely to use services in an ED. However, people having SPD and being a heavy drinker did not have a significantly elevated risk of ED use.

Conclusion

An association between SPD and ED use among US young adults is established in this study. Attempts to decrease excess ED use and the development of strategies to improve mental health among young adults are needed to improve patient health and reduce the health-care burden of high costs and deteriorating ED care quality.     

A Conceptual Model for Behavioral Health and Primary Care Integration: Emerging Challenges and Strategies for Improving International Mental Health Services

In many countries, there is a growing concern about the lack of coordination and integration of primary care with services for mental and substance-use conditions: Care is all too often fragmented across the spectrum of general medical and specialty behavioral health systems. This fragmentation tends to perpetuate systems of care that are not sensitive to the needs of individuals, provide poor quality of care, and produce inconsistent health outcomes. General health care functions across a continuum of care that includes prevention, primary care, and chronic care management. The articulation of the common elements in general and behavioral health care along that continuum has the potential to foster a framework for enhanced coordination of care for individuals in the context of improved systems of care that better supports recovery and favorable health outcomes.     

Impact of insurance status on access to care and out-of-pocket costs for U.S. individuals with epilepsy

We analyzed data from the 2002–2007 Medical Expenditure Panel Survey (MEPS) to assess whether individuals with epilepsy who are uninsured and those who have Medicaid coverage experience differences in medical resource utilization or out-of-pocket costs compared with those having other types of insurance. With sociodemographic characteristics controlled for, uninsured individuals had significantly fewer outpatient visits, fewer visits with neurologists, and greater antiepileptic drug costs than did those with private insurance. Individuals with Medicaid coverage had similar medical resource utilization rates but lower out-of-pocket costs compared with privately insured individuals. These findings indicate substantial barriers to receipt of appropriate medical care for uninsured individuals with epilepsy, but not for those with Medicaid coverage. Future studies should evaluate whether ongoing changes to the US health care system are able to address the differences in care we found among uninsured individuals with epilepsy and should incorporate measures of disease severity and unmet need.     

Community Mental Health Center Integrated Care Outcomes

Despite the compelling logic for integrating care for people with serious mental illness, there is also need for quantitative evidence of results. This retrospective analysis used 2013–2015 data from seven community mental health centers to measure clinical processes and health outcomes for patients receiving integrated primary care (n?=?18,505), as well as hospital use for the 3943 patients with hospitalizations during the study period. Bivariate and regression analyses tested associations between integrated care and preventive screening rates, hemoglobin A1c levels, and hospital use. Screening rates for body-mass index, blood pressure, smoking, and hemoglobin A1c all increased very substantially during integrated care. More than half of patients with baseline hypertension had this controlled within 90 days of beginning integrated care. Among patients hospitalized at any point during the study period, the probability of hospitalization in the first year of integrated care decreased by 18 percentage points, after controlling for other factors such as patient severity, insurance status, and demographics (p?<?.001). The average length of stay was also 32% shorter compared to the year prior to integrated care (p?<?.001). Savings due to reduced hospitalization frequency alone exceeded $1000 per patient. Data limitations restricted this study to a pre?/post-study design. However, the magnitude and consistency of findings across different outcomes suggest that for people with serious mental illness, integrated care can make a significant difference in rates of preventive care, health, and cost-related outcomes.     

Relationship Between Preventative Physical Health Care and Mental Health in Individuals with Schizophrenia: A Survey of Caregivers

The relationship between preventative physical health care and mental health in individuals with schizophrenia was assessed retrospectively by questionnaires completed by 504 caregivers. Psychiatric symptom severity and quality-of-life data on 332 respondents were evaluable. Suboptimal preventative physical health care was defined as absence of ≥2 examinations within a specified time: physical and dental within 12 months, eye within 24 months. Findings revealed similar use of mental health care services for all individuals, but those in the suboptimal physical health care group (n = 93 [28%]) had a lower quality of life (p < .011), more negative symptoms (p < .009), less paid employment (p < .001), and more alcohol/drug abuse (p = .02). These findings suggest that mental health care providers should play a more active role in monitoring the basic physical health care of patients with schizophrenia.     

Psychiatry's future: Facing reality

U.S. public and private health care costs, including mental health treatment costs, continue to rise at unacceptably high annual rates of increase. "Basic" health insurance plans presently being developed by both public and private payers, in response to this crisis, will include: (1) severely limited coverage for psychiatric care; and (2) coverage for specific categories of serious mental illness. Psychiatrists must develop cost-effective goals and treatment standards that achieve satisfactory outcomes for these high-priority conditions. Treatment standards must be compatible with economic reality. Psychiatry as a profession (i.e., all psychiatrists) must accept cost-effective treatment responsibility for society's most seriously mentally ill individuals. We need to train psychiatrists who are biologically-, crisis-, and rehabilitation-oriented and who can practice effectively and comfortably within society's treatment expectations and funding constraints.