The response of an assertive community treatment program following a natural disaster

A newly forming model treatment program for seriously mentally ill adults was dramatically affected by a natural disaster in September 1989. Hurricane Hugo rendered the offices of the Assertive Community Treatment Program uninhabitable, its vehicles marginally driveable, and its resources virtually nonexistent. In the three months following the storm, however, not a single psychiatric rehospitalization took place. Although the authors cannot claim that the program model was solely responsible for this outcome, this paper illustrates the service system elements that contributed to the program's effectiveness in the wake of one of the nation's most severe natural disasters.

Ethnic differences in use of inpatient mental health services by blacks, whites, and Hispanics in a national insured population

OBJECTIVE

We examine whether ethnic differences in use of inpatient mental health services exist when the usually confounding effects of minority status and culture are minimized or controlled.

DATA SOURCES AND STUDY SETTING

Secondary analyses were conducted using a national insurance claims database for 1.2 million federal employees and their dependents insured by the Blue Cross/Blue Shield (BC/BS) Federal Employees Plan (FEP).

STUDY DESIGN

The Andersen-Newman model of health utilization was used to analyze predisposing, enabling, and need variables as predictors of inpatient mental health utilization during 1983. The study design was cross-sectional.

DATA COLLECTION

The study database was made up of BC/BS insurance claims, Office of Personnel Management employee data, and Area Resource File data.

PRINCIPAL FINDINGS

No significant differences were found among blacks, whites, and Hispanics in the probability of a psychiatric hospitalization or in the number of inpatient psychiatric days. Regression analyses revealed younger age and psychiatric treatment of other family members as significant predictors of a hospitalization; region of residence, younger age, hospital bed availability, and high option plan enrollment were significant predictors of the number of treatment days.

CONCLUSIONS

Ethnic differences in use of inpatient mental health services were not significant in this generously insured population. Further research involving primary data collection among large and diverse samples of ethnic individuals is needed to fully examine the effects of cultural and socioeconomic differences on use of mental health services.

Ethnicity and the use of outpatient mental health services in a national insured population

OBJECTIVES

Factors affecting ethnic differences in the use of outpatient mental health services are analyzed in an insured, nonpoor population to determine if lower use by Blacks and Hispanics persists when socioeconomic and other factors are controlled.

METHODS

To identify significant predictors of the probability and amount of use, insurance claims data for a population of 1.2 million federal employees insured by Blue Cross/Blue Shield in 1983 were analyzed with the Andersen and Newman model of health service utilization. Logistic and ordinary least squares regression models were estimated for each ethnic group.

RESULTS

Blacks and Hispanics had lower probabilities and amounts of use when compared with Whites after controlling for a number of variables.

CONCLUSIONS

Since ethnic differences in the use of outpatient mental health services exist even in an insured, nonpoor population, factors other than lower socioeconomic status or insurance coverage--for example, cultural or attitudinal factors and service system barriers--are likely responsible. Such findings have policy implications in the current climate of health care reform to increase access to care for the underserved.

How can epidemiology improve mental health services for children and adolescents?

Epidemiology, the study of patterns of disease distribution in time and space, can help to improve mental health services for children and adolescents by increasing understanding of the causes, development, and course of psychiatric disorders. For the purpose of service delivery, epidemiologic research on child psychopathology can provide information on need for services, availability of services, and effectiveness of services. For both scientific and planning purposes, epidemiologic research can inform us about (1) the developmental course of psychiatric disorders during childhood and adolescence, (2) the effect of psychiatric disorder on the course of normal childhood development, and (3) the effect of childhood development on the developmental course of psychiatric disorder. Information about prevalence and incidence is useful for planning primary, secondary, and tertiary prevention and treatment services. The same information is scientifically useful to the extent that it helps to answer questions about causation, course, and outcome. However, one aim of this paper is to show that epidemiology is about a great deal more than rates of disorder.

A pilot study of assertive community treatment for patients with chronic psychotic disorders

This study measured hospital utilization and residential status of 51 patients with chronic psychoses before and after a 1-year program of assertive community treatment. Time hospitalized was reduced by 94%, and 82% of the patients previously living in hospitals or group homes attained independent living status, suggesting that this form of clinical management may reduce institutional care and costs to mental health care systems.

Mental health service use by the elderly in nursing homes

OBJECTIVES

Because current Omnibus Budget Reconciliation Act regulations influence the disposition of US nursing home residents who have mental illness, National Nursing Home Survey (1985) data are analyzed for predictors of mental health service use.

METHODS

Elderly residents' rates of mental health service use are presented. Logistic regression yielded odds ratios for treatment by both mental health specialists and general practitioners for client and service system variables.

RESULTS

Among the two thirds of elderly residents with a mental disorder (including dementia), only 4.5% receive any mental health treatment in a 1-month period. The ratio of specialist to general practitioner care is approximately 1:1. Patients seen by a specialist are likely to be younger (aged 65 to 74); live in the Northeast; and have a diagnosis of schizophrenia (13:1), dementia (3:1), or other mental disorders (5:1). Prior residence in a psychiatric hospital predicts care by both health professional types. Rural location, nonproprietary ownership of the nursing home, and aggressive behavior point to general physician care.

CONCLUSIONS

Our findings indicate significant neglect of the mental health needs of older nursing home residents and underscore the importance of monitoring the regulations for screening and treatment of mental disorders under the Omnibus Budget Reconciliation Act.

The effect of insurance benefit changes on use of child and adolescent outpatient mental health services

Use of outpatient mental health services by dependent children younger than 18 years of age enrolled in the Blue Cross and Blue Shield Federal Employees Plan (FEP) is examined in 1978 and 1983 focusing on a cut in benefits and a shift from high- to low-option plan enrollment between those years. While use rates increased from 2.13% to 2.76% by 1983, the average number of visits decreased from 18.9 to 12.8. High-option plan use exceeded low-option plan use in both years--2.26% versus 0.81% in 1978 and 3.58% versus 1.93% in 1983. In addition to benefit plan, ethnicity, parent's education, type of provider, and type of treatment setting also significantly predicted amount of use. Despite the strong evidence of the effects of benefit coverage, it is likely that need exceeded use even in this insured population of children and adolescents. Implications of the findings are discussed in the context of recent dramatic changes in mental service delivery including privatization, managed care initiatives to cut costs, and growing pressures for national health insurance.

Use of inpatient services by a national population: do benefits make a difference?

This study describes changes in the use of inpatient mental health services by children and adolescents under age 18. The data were insurance claims from the Blue Cross and Blue Shield Federal Employees Program. The study focused on a cut in inpatient benefits that occurred between 1978 and 1983. The rate of inpatient hospitalization dropped significantly, and the average number of days also decreased significantly from 45.8 to 27.0 days. This study is among the first to demonstrate that the rate and amount of inpatient care provided for children and adolescents is responsive to variations in benefit coverage.

Serious physical illness as a stressor: effects on family use of medical services

The purpose of this study was to investigate the effect of stress on the family due to the hospitalization of a family member for a serious chronic illness. The data were the health insurance claims of 3,591 families obtained from the largest U.S.A. insurer of federal employees. It was hypothesized that the nonhospitalized family members would have a stress-related increase in medical expenses for some period of time after the chronically ill person was hospitalized. Multiple regression analysis with adjustments for a number of covariates found increases in mean medical charges of $326 per person (p less than 0.01) (excluding the hospitalized person) in the 3 years following the hospitalization. This finding lends support to the theory that stress--in this case, hospitalization of one family member--affects the entire family system. No significant differences were found in medical charges between families who did and did not receive mental health treatment following the hospitalization.

Initial level of care and clinical status in a managed mental health program

Data from 9,055 adult intakes performed over two and a half years of a managed mental health care demonstration project in a large U.S. city were used as indirect measures of quality of care. The level of care to which patients were initially assigned was examined in relation to the patients' clinical status as judged by both managed care case managers and treatment providers. During the period, assignment to inpatient care of patients in almost every clinical category decreased. The decrease seemed to reflect a policy decision to limit use of all inpatient services rather than a selective elimination of unnecessary hospitalization. Case managers rated a smaller proportion of patients severely disturbed, partial hospitalization was rarely used as an alternative to inpatient care, and detoxification services were increasingly used as an inpatient alternative. Although these data reinforce common beliefs about managed care, the quality of managed care programs can be accurately assessed only with data collected specifically for evaluation purposes.

Measuring the outcomes of care for mental health problems. The case of depressive disorders

To conduct effectiveness research in mental health, many nontrivial problems need to be addressed. A multidisciplinary expert panel designed an outcomes module for major depression and dysthymia to measure disease-specific outcomes, treatments routinely provided, and patient characteristics that influence treatment or its outcomes. The outcomes module was pilot-tested to evaluate its ability to identify a diagnostically homogeneous group of patients, to establish its reliability and validity, and to assess the feasibility of administering the module in a mental health setting. In a cohort of 40 patients, the module identified all 31 patients who had a research diagnosis of major depression or dysthymia (100% sensitivity), and 2 of 9 patients who did not have this diagnosis (77.8% specificity). The outcomes module measured key constructs accurately enough to discriminate between groups of depressed patients expected to differ, indicating positive construct validity. High rates of instrument completion supported the feasibility of using the module in specialty settings. Extensive efforts locating patients for follow-up will be needed to draw valid conclusions about treatment effectiveness.

Evaluation of a Maryland fiscal incentive plan for placing state hospital patients in nursing homes

In Maryland a six-month fiscal incentive to promote nursing homes' acceptance of chronic patients discharged from state psychiatric hospitals was evaluated after one year. During the fiscal year of the incentive program, such placements (N = 182) increased an average of 38 percent from previous years. Of 163 patients whose placements were evaluated, 22 were returned to the state hospital during the six-month period that the incentive was in place. Ten of the 22 were returned within 30 days of placement. Contrary to expectation, the return rate did not rise after the incentive was discontinued; four patients were returned during the second six months of the study period. Most returns during the first six months were due to patients' physical and verbal threats. The results supported the use of short-term fiscal incentives and emphasized the importance of intensive supportive interventions with chronic mentally ill patients early in the nursing home placement.

Mental illness in nursing homes

This report presents statistics on residents of nursing homes who had at least one condition that can be classified as a mental illness. Data for this major subgroup of nursing home residents are presented by length of stay since admission, source of payment in the month before the survey, functional dependencies in the activities of daily living, usual living arrangements prior to admission, and reasons for admission, according to major demographic and facility characteristics. This report also includes selected comparisons between residents with and without mental disorders. Estimates are based on data collected in the 1985 National Nursing Home Survey.

Mental health service use by adolescents in the 1970s and 1980s

Shifts in the use of mental health services by adolescents between 1975 and 1986 are examined by levels of care--outpatient, partial hospitalization, residential treatment center, and inpatient. Data from National Institute of Mental Health surveys of U.S. facilities include client characteristics (age, sex, race, diagnosis, clinical history) and treatment characteristics (referral source, type of intervention, length of stay). Major increases in mental health service use were observed for all levels of care during this period. Nonetheless, a relatively small percent (less than 2%) of adolescents in the U.S. received any type of mental health service in 1986. The clinical and treatment variables available were only moderately helpful in differentiating levels of care.

Phobia: prevalence and risk factors

This article is the presentation of the main phobia data from the Epidemiologic Catchment Area (ECA) program, with a sample size of n = 18.571. Work on this article was initiated in 1981 at the beginning of the ECA study, but publication has been delayed a decade. Phobias are determined from information from the Diagnostic Interview Schedule (DIS), classified according to DSM III. Phobias are found to be the most common psychiatric disorder in the community, more common than major depression or alcohol abuse or dependence in the month prior to interview. The one month prevalence is between 4.0 and 11.1%, with the estimated prevalence in the United States being 6.2%. There were nine community surveys of the prevalence of phobia that pre-dated the ECA studies, which found a wide range of prevalence rates from 1.2% to 26.1%. By far the strongest risk factor associated with phobias is the presence of another psychiatric disorder. Prevalence rates of simple phobia and agoraphobia are found in the ECA studies to be significantly higher in women; social phobia, which is less prevalent, has no significant sex difference. The prevalence rates are higher in younger age groups, and in those with low socioeconomic status (SES). The onset of phobias occurs primarily in the childhood or teenage years, and they tend to be chronic conditions. Less than a quarter of phobics receive treatment.

The identification of psychiatric illness by primary care physicians: the effect of patient gender

OBJECTIVE

This study tested several hypotheses about why women are more likely than men to have psychiatric disorders noted by their primary care physicians.

DESIGN

Patients were screened for mental disorders using the General Health Questionnaire. A stratified sample was assessed using the Schedule for Affective Disorders and Schizophrenia. Information on utilization and identification of mental health problems was abstracted from the medical records.

SETTING

The study was conducted at a multispecialty group practice in a semirural area of Wisconsin.

PATIENTS

Study participants consisted of a stratified probability sample of 247 patients seeking primary care.

RESULTS

Patients with a psychiatric illness who were relatively frequent users of the clinic were most likely to be identified by a physician as having a mental health problem. When psychiatric illness and utilization rates were statistically controlled, men and women had comparable identification rates.

New directions in research on assertive community treatment

Evaluation of assertive community treatment programs has demonstrated that they are highly effective in reducing the need for psychiatric hospitalization of chronic mentally ill patients. However, the programs also tend to cost more than traditional outpatient care, and their impact on other areas of patient functioning is not clear. The authors believe more rigorous studies of the programs are needed before policymakers can properly evaluate their role in the overall mix of services. Future studies should extend previous research by comparing the programs to current state-of-the-art treatment in community mental health centers or county mental health programs; assessing the total system costs of assertive community treatment programs, as well as the amount of cost shifting by payers; analyzing outcomes of clients in mature programs over longer time periods; standardizing the measurement of various client outcomes; and determining the impact of individual program elements--alone and in combination--on different subgroups of clients.

Chronic stressors and maternal depression: implications for prevention

We report on the use of an instrument to measure exposure to stressors among 149 women presenting with their children for pediatric care at an urban primary care center. Overall, 38.3 percent of the women had significant levels of depressive symptoms; 71.4 percent of those in the "high stress" group had an adjusted prevalence odds ratio of 5.00 [95% CI = 2.12, 11.82]. We conclude that screening in the pediatric office is feasible for identifying women at high risk of becoming depressed.

Prescribing of psychotropics in elderly nursing home patients

This study examined the prescribing of psychotropic drugs for patients 65 years of age and older in nursing homes using data from the 1984 National Nursing Home Survey pretest. The most frequently used antipsychotic, anxiolytic, antidepressant, and sedative/hypnotic medications were respectively: haloperidol, hydroxyzine, doxepin, and temazepam. Results indicate that more than one-fifth of the patients having orders for psychotropic medications did not have a documented mental disorder. More than one-fourth of the study patients had orders for more than one psychotropic medication. Nursing home patients who received psychotropics had concurrent orders for an average of 3.3 nonpsychotropic medications, many of which could increase the possibility of drug interactions and potential side effects.

The construct validity of the ischemic score of Hachinski for the detection of dementias

Two hundred forty-one nursing home patients from the National Nursing Home Survey Pretest were assessed using the Ischemic Score of Hachinski. Medical chart diagnoses were used to classify those with and without dementia. The Mini-Mental State Examination was used to assess the accuracy of the medical-chart diagnoses of dementia. The Ischemic Score failed to differentiate multi-infarct dementia from other types of dementias. Instead, the difference between the two dementia groups was in the direction opposite that predicted by Hachinski.

Psychiatric disorders in pediatric primary care. Prevalence and risk factors

Children aged 7 to 11 years visiting their primary care pediatrician for a wide range of reasons were studied to determine the one-year prevalence of DSM-III disorders and the risk factors associated with them. Parents completing the Child Behavior Checklist about their children identified problems that placed 24.7% of 789 children in the clinical range. Detailed psychiatric interviews with 300 parents and children, using the Diagnostic Interview Schedule for Children, yielded a one-year weighted prevalence of one or more DSM-III disorders of 22.0% +/- 3.4%, combining diagnoses based on either the child or the parent interview.

Psychopathology in pediatric primary care: the new hidden morbidity

In a study of emotional and behavioral problems seen in children attending pediatric primary care clinics in a health maintenance organization, parents of 789 children 7 to 11 years of age completed a behavior screening questionnaire, the Child Behavior Checklist. Of the 195 (24.7%) children identified by the checklist as disturbed, 126 were given a detailed psychiatric assessment using the Diagnostic Interview Schedule for Children, a structured psychiatric interview of known validity and reliability. A randomly selected group of 174 nondisturbed children was also assessed. The pediatricians' judgment about the presence of emotional and behavioral problems, made at the index clinic visit, was compared with diagnoses made from the computer-scored interviews. Pediatricians diagnosed one or more such problems in 5.6% of the children (weighted estimate: 95% confidence limits 3.8% to 7.6%), compared with 11.8% (95% confidence interval 9.3% to 13.5%) based on the interview with the parent. Pediatricians were highly specific, ie, 84% of children assessed as nondisturbed had no psychiatric disorder, but they showed low sensitivity, ie, they only identified 17% of the children with behavioral or emotional problems, giving a "hidden morbidity rate" of 83% (ie, 83% of cases were not identified). The role of primary care pediatricians in the identification, prevention and treatment of what has been called "the new morbidity" is discussed. We suggest that, on the basis of these findings, emotional and behavioral problems in children have to be seen as "the new hidden morbidity."