Alcohol and substance use history among ADHD adults: the relationship with persistent and remitting symptoms, personality, employment, and history of service use

OBJECTIVE

To profile substance use, personality, service use, and employment in adults with ADHD.

METHOD

The sample consisted of 216 consecutive referrals to an adult ADHD service and classified with ADHD, partially or fully remitted ADHD, or no ADHD. Normal controls (n = 33) were recruited from a general practitioner's center. Participants completed measures of alcohol and illicit substance use, employment, service use, ADHD symptoms, and personality.

RESULTS

High rates of substance use were found in participants with current ADHD diagnoses. ADHD participants showed increased rates of personality trait or disorder scores and unemployment. There was some indication that those with ADHD and substance-related impairment place higher demand on services. Individuals with partially remitted ADHD showed similar substance use to those with current ADHD, whereas those in full remission were comparable with normal controls.

CONCLUSION

Although ADHD symptoms may remit with time, individuals retaining persisting or partial symptoms have substantial needs in adulthood.

Use of maternal health services by remote dwelling Aboriginal women in northern Australia and their disease burden

BACKGROUND

Disparities exist in pregnancy and birth outcomes between Australian Aboriginal women and their non-Aboriginal counterparts. Understanding patterns of health service use by Aboriginal women is critical. This study describes the use of maternal health services by remote dwelling Aboriginal women in northern Australia during pregnancy, birth and the postpartum period and their burden of disease.

METHODS

A retrospective cohort study of maternity care for all 412 maternity cases from two remote Aboriginal communities in the Northern Territory of Australia, 2004-2006. Primary endpoints were the number and type of maternal health-related complications and service episodes at the health centers and regional hospital during pregnancy, birth, and the first 6 months postpartum.

RESULTS

Ninety-three percent of women attended antenatal care. This often commenced late in pregnancy. High levels of complications were identified and 23 percent of all women required antenatal hospitalization. Birth occurred within the regional hospital for 90 percent of women. By 6 months postpartum, 45 percent of women had documented postnatal morbidities and 8 percent required hospital admission. The majority of women accessed remote health services at least once; however, only one third had a record of a postnatal care within 2 months of giving birth.

CONCLUSION

Maternal health outcomes were poor despite frequent service use throughout pregnancy, birth, and the first 6 months postpartum suggesting quality of care rather than access issues. These findings reflect outcomes that are more aligned with the developing rather than developed world and have significant implications for future planning of maternity services that must be urgently addressed.

Case managed community aged care: what is the evidence for effects on service use and costs?

OBJECTIVE

To evaluate the effects of case management in community aged care (CMCAC) interventions on service use and costs.

METHOD

Five databases were searched from inception to 2011 July to include randomized control trials and comparative observational English studies. Results were summarized by using the best-evidence synthesis approach.

RESULTS

Twenty-one studies were included. Available studies supported improvements in clients' use of case management services (all of the four studies), some community services (8 of the 10) and nursing home admission and stay (around one half), delay of nursing home placement (all of the two studies), and achieving cost neutrality (8 of the 11). The effects on medical care utilization were varying.

DISCUSSION

In general, these positive effects justify the further development and refinement of CMCAC programs. Result applicability is limited by only including English studies. Cost studies applying a societal perspective, and full economic appraisals where appropriate are warranted.

Finnish female prisoners - heavy consumers of health services

AIMS

Previous prison studies show that female prisoners often have more health problems than male prisoners do and that they have many chronic health conditions. Few studies have been made among offenders concerning the use of health services, and even fewer concerning physical diseases. We studied the self-reported lifetime somatic diseases, the use of health services and the current use of prescription medicines among Finnish female prisoners and compared them with males.

METHODS

The sample consisted of 101 females and 309 male prisoners as controls. The study included several questionnaires and interviews conducted by experienced prison nurses.

RESULTS

The women had more commonly genitourinary, virus hepatitis/HIV infections and group "other diseases" than the men. Over 80% of the women and men have had accidents/injuries. Four out of five women, and half of the men, used some medicine regularly. Of the females, 92% (80% of the males) reported lifetime hospital care and 65% (61%) treatment in surgery department, respectively; 70% of the females (53% of the males) reported lifetime use of any psychiatric service; 66% of the women (46% of the men) had received psychiatric out-patient services, and 43% (31%) psychiatric in-patient hospital care and 38% (30%) substance abuse services, respectively.

CONCLUSIONS

The heavy use of health services among female prisoners resulted mainly from the use of services for substance use and other mental disorders and treatment in surgery department. Compared to men, the difference in using health services was associated with psychiatric services.

Conceptual measurement framework for help-seeking for mental health problems

BACKGROUND

Despite a high level of research, policy, and practice interest in help-seeking for mental health problems and mental disorders, there is currently no agreed and commonly used definition or conceptual measurement framework for help-seeking.

METHODS

A systematic review of research activity in the field was undertaken to investigate how help-seeking has been conceptualized and measured. Common elements were used to develop a proposed conceptual measurement framework.

RESULTS

The database search revealed a very high level of research activity and confirmed that there is no commonly applied definition of help-seeking and no psychometrically sound measures that are routinely used. The most common element in the help-seeking research was a focus on formal help-seeking sources, rather than informal sources, although studies did not assess a consistent set of professional sources; rather, each study addressed an idiosyncratic range of sources of professional health and community care. Similarly, the studies considered help-seeking for a range of mental health problems and no consistent terminology was applied. The most common mental health problem investigated was depression, followed by use of generic terms, such as mental health problem, psychological distress, or emotional problem. Major gaps in the consistent measurement of help-seeking were identified.

CONCLUSION

It is evident that an agreed definition that supports the comparable measurement of help-seeking is lacking. Therefore, a conceptual measurement framework is proposed to fill this gap. The framework maintains that the essential elements for measurement are: the part of the help-seeking process to be investigated and respective time frame, the source and type of assistance, and the type of mental health concern. It is argued that adopting this framework will facilitate progress in the field by providing much needed conceptual consistency. Results will then be able to be compared across studies and population groups, and this will significantly benefit understanding of policy and practice initiatives aimed at improving access to and engagement with services for people with mental health concerns.

Caregiver burden, health utilities, and institutional service use in Alzheimer's disease

OBJECTIVE

This study examined the moderating effect of caregiver burden on the relationship between the health status of Alzheimer's disease (AD) patients and their use of institutional services (i.e., hospitalization, nursing home, and residential care).

METHODS

Data were obtained at baseline and at 3, 6, and 9 months following study entry on 421 community-dwelling patients with AD in the Clinical Antipsychotic Trials of Intervention Effectiveness for AD. The outcome variable includes use of any institutional services. Logistic regression was employed to estimate the interaction between Health Utility Index Mark III score (a general health status measure) and four concurrent caregiver burden measures at outcome. Marginal effects were calculated and plotted using random effects models for observations at multiple time points per individual. Average effects were calculated across all observations using models without random effects.

RESULTS

Random effects results suggest that caregiver burden weakens the inverse relationship between health utilities and institutional service use, leading to greater likelihood of institutional use than would be expected at a given level of health. This is indicated by positive and significant signs on the Health Utility Index Mark III*caregiver burden interaction when burden is measured using the Caregiver Distress Scale, Beck Depression Inventory, and Caregiver Assessment Survey (all p < 0.05). It is reinforced by positive and significant average effects deriving from Caregiver Distress and Beck Depression Inventory models without random effects (both p < 0.10). Results derived from the Burden Interview Scale, although positive, were non-significant and weak by comparison.

CONCLUSION

Caregiver support interventions should be offered to individuals caring for less-advanced AD patients. Otherwise, healthy patients may be at increased risk for institutionalization when caregivers experience high levels of burden.

Use of Community and School Mental Health Services by Custodial Grandchildren

We examined patterns and predictors of the perceived need, use, and unmet need for mental health services by custodial grandchildren within both the school-based and community-based delivery sectors. Data were self-reported by a national sample of 610 custodial grandmothers providing full-time care to grandchildren ages 6 to 17 in the absence of biological parents. Although overlapping use of services across both sectors was common, the overall use of school-based services (51%) was higher than that of community-based services (37%). Using theAndersen Social and Behavioral Model (1995) the following shared predictors of mental health service use across both sectors by custodial grand-families emerged: grandchildren's externalizing symptoms, having other grandchildren in the household with medical or psychiatric diagnoses and corresponding use of services in the other sector. Predictors were largely the same regardless of whether analyses were conducted with families recruited by probability or convenience based sampling methods. Findings suggest the necessity to coordinate and integrate the availability and implementation of mental health services for custodial grandchildren across different delivery sectors.

Mental health service utilization for psychiatric disorders among Latinos living in the United States: the role of ethnic subgroup, ethnic identity, and language/social preferences

PURPOSE

To examine aspects of Latino experience in the US as predicting service utilization for mood, anxiety, and substance disorders.

METHODS

Latino participants 18 and older in the NESARC (N = 6,359), a US national face to face survey. Outcomes were lifetime service utilization for DSM-IV lifetime mood/anxiety or substance disorders, diagnosed via structured interview (AUDADIS-IV). Main predictors were ethnic subgroup, ethnic identity, linguistic/social preferences, nativity/years in the US, and age at immigration.

RESULTS

Higher levels of Latino ethnic identity and Spanish language/Latino social preferences predicted lower service utilization for mood disorders [ethnic identity OR = 0.52, language/social OR = 0.44] and anxiety disorders [ethnic identity OR = 0.67, language/social OR = 0.47], controlling for ethnic subgroup, disorder severity, time spent in the US, and economic and practical barriers Service utilization for alcohol/drug disorders was low across all Latino subgroups, without variation by examined predictors.

CONCLUSION

Ethnic/cultural factors are strong determinants of service utilization for mood/anxiety, but not substance use disorders among Latinos in the US strategies to increase service utilization among Latinos with psychiatric disorders should be disorder specific, and recognize the role of ethnicity and identity as important components of a help-seeking model.

Use of services by community-dwelling patients with dementia: a systematic review

Dementia is a complicated disease requiring medical, psychological, and social services. Services to address these needs include medical care (outpatient physician/specialist, inpatient, emergency) and community care (home health, day care, meal preparation, transportation, counseling, support groups, respite care, physical therapy). This systematic review of articles published in English from 1991 to the present examines studies of ambulatory, community-dwelling dementia patients with established dementia diagnoses. Searches of the Medline database using 13 combinations of search terms, plus searches of Embase and PsycINFO databases using 3 combinations of terms and examination of reference lists of related articles, resulted in identification of 15 studies dealing with healthcare utilization among community-dwelling dementia patients in both medical and community care settings. Patients with dementia frequently use the full spectrum of medical services. Community resources are used less frequently. Community healthcare services may be a valuable resource in alleviating some burden of dementia care for physicians.

Social network influences on service use among urban, African American youth with mental health problems

PURPOSE

To examine the associations between the size and quality of African-American adolescents' social networks and their mental health service use, and to examine whether these social network characteristics moderate the association between need for services because of emotional or behavioral difficulties and use of services.

METHOD

Participants were a community sample of African-American adolescents (N = 465; 46.2% female; mean age, 14.78) initially recruited in 1st grade for participation in an evaluation of two preventive intervention trials. Social network influences and adolescents' mental health service use in schools and community were accessed.

RESULTS

A significant positive association between adolescents' perception that their social network was helpful and their use of school mental health services was identified. The significant associations between need for services for anxiety, depression, or behavior problems, and school and outpatient service use were moderated by size of the social network. Specifically, among youth in need of services for anxiety or depression, school-based service use was higher for those with larger social networks.

CONCLUSIONS

Implications for enhancing access to formal mental health services include further examination of key social network influences that potentially serve as facilitators or barriers to formal help-seeking. The findings also suggest that it might be important to integrate social network members into interventions to address the mental health needs of adolescents.

Service use among Mexico City adolescents with suicidality

BACKGROUND

We report the lifetime and 12-month prevalence and associations of mental health treatment among Mexican adolescents with suicide-related outcomes (SROs; including ideation, plans, gestures and attempts).

METHODS

A representative multistage probability household survey of 3005 adolescents aged 12 to 17 years residing in the Mexico City Metropolitan Area was carried out in 2005. Discrete-time survival analyses were used to assess the relationships between SROs and receiving treatment for emotional, alcohol, or drug problems.

RESULTS

The prevalence of lifetime service use among respondents with SROs was 35% for those with ideation only, 44% for those with ideation and plan, 49% for those with gesture and 50% for those with attempt; the prevalence of 12-month service use was 10%, 24%, 6% and 21%, respectively. Timing between onset of SRO and receiving treatment for emotional, alcohol, or drug problems showed that about 50% of adolescents will have contact with a service provider before developing any SRO. Healthcare professionals were the most likely to be consulted, followed by school-based programs.

LIMITATIONS

This survey was limited to adolescents living in one of the largest metropolitan areas in the world and the analyses used data on retrospectively reported ages of onset that are subject to recall errors.

CONCLUSIONS

Most suicidal adolescents do not receive treatment, and many adolescents develop their suicidality in spite of prior contacts with service providers. Interventions to increase treatment, prevention, and monitoring are sorely needed for this vulnerable population.

Medical and supportive care among people with ALS in the months before death or tracheostomy

People with amyotrophic lateral sclerosis (ALS) who choose tracheostomy demonstrate a strong and mostly consistent attachment to life from the point of diagnosis. It is unclear if these patients also use medical and health services to a greater degree than patients who decide against tracheostomy. In this research, patients with a high likelihood of dying over six months (forced vital capacity <50% predicted) were followed monthly until death or tracheostomy with long-term mechanical ventilation (LTMV). Patient service use was measured by caregiver reports of 1) ALS-specific prosthetic devices, 2) allied health or medical services, 3) legal preparation for medical care or the end of life, and 4) medical care episodes. Caregivers also reported all patient prescription medications. At follow-up, 57 patients died and 14 elected to have tracheostomy and LTMV. Patients who opted for LTMV were younger and had higher household incomes. They were significantly more likely to use nasal ventilation, paid home care, and family or personal counseling over follow-up, and they were also more likely to remain on medications. The proactive orientation to health and desire to live despite severe disability reported for people choosing LTMV thus extends as well to more intensive use of medical and supportive care in the months before tracheostomy. A challenging task for clinicians is to acknowledge this strong desire to live while providing appropriate expectations for life after tracheostomy.

CHILDREN'S MENTAL HEALTH SERVICE USE AND MATERNAL MENTAL HEALTH: A PATH ANALYTIC MODEL

OBJECTIVE: This observational study explores pathways towards any past year use of child mental health services. METHODS: Data from the 2002 National Survey of American Families were used to explore the relationship between past month maternal mental health and past year child mental health services use. Observations were limited to the 8072 most knowledgeable adults who were the mothers of target children aged 6-11. Logistic regressions were performed to determine the odds of any child mental health service use followed by path analyses using Maximum Likelihood estimation with robust standard errors. RESULTS: Multiple factors were associated with odds of any child mental health service use. In the path analytic model poor past month maternal mental health was associated with increased aggravation which in turn was associated with increased use of mental health visits. Negative child behaviors as reported by the mother were also associated with increased maternal aggravation and increased service use. CONCLUSIONS: Parental perception of child behaviors influences treatment seeking, both directly and indirectly through parental aggravation. Parental mental health influences tolerance for child behaviors. Findings are consistent with other studies. Interventions should address the entire family and their psychosocial circumstances through collaboration between multiple service sectors.

Success of mental health referral among pregnant and postpartum women with psychiatric distress

OBJECTIVE

This study measured rates of and determined factors associated with mental health service use among a cohort of 465 pregnant and postpartum women receiving care from publicly funded obstetric clinics.

METHODS

Women underwent a diagnostic evaluation, were provided with at least one mental health referral and were encouraged to seek treatment; follow-up with provision of additional referrals occurred at 1, 3 and 6 months after the initial assessment. Logistic regression was used to estimate the relationship between clinical and psychosocial factors and self-reported mental health service use.

RESULTS

Of the referred women, 38.1% attended at least one mental health visit, while only 6% remained in treatment during the entire 6-month follow-up interval. Postpartum women were more likely than pregnant women to attend a mental health treatment visit [odds ratio (OR)=4.17]. Being born in the United States (OR=2.06), being exposed to interpersonal violence (OR=2.52) and being unemployed (OR=2.69) were associated with attending at least one mental health-care visit. Women who received a behavioral health referral to the same site as their prenatal or postpartum care were more likely than those referred offsite to attend a mental health treatment visit (OR=3.23).

CONCLUSIONS

Despite active follow-up, rates of accessing and particularly continuing in mental health treatment were low. More work is needed to support the integration of specialty behavioral health services in primary care settings accessed by perinatal women.

Five Years On: Public Sector Service Use Related to Mental Health in Young People with ADHD or Hyperkinetic Disorder Five Years After Diagnosis

BACKGROUND

  Little is known about ongoing service use among young people with ADHD, but this information is important to the development of services to support these young people.

METHODS

  A cohort of young people with ADHD or hyperkinetic disorder (n = 115) was followed up five to seven years after diagnosis. Details are presented of their use of public sector services over the 12 months preceding reassessment, compared to young people with ADHD from a large epidemiological study.

RESULTS

  Most children remained in contact with CAMHS, with high rates of contact with schools, educational professionals and the criminal justice system. Nearly all had taken medication at some point, while many still were using it. There were low reported rates of psychological and group interventions within the last twelve months, but this does not rule out earlier access to such treatments.

CONCLUSIONS

  Children with ADHD utilise long-term support from public sector services, and cross agency strategies or clinics may help to optimise functioning.

The Effect of Racial Socialization on Urban African American Use of Child Mental Health Services

OBJECTIVE: To examine how parental endorsement of racial socialization parenting practices relates to child mental health service use among an urban sample of African American families. METHODS: A cross-sectional sample of urban African American parents (n = 96) provided ratings of their beliefs concerning various dimensions of racial socialization constructs, i.e., spiritual or religious coping (SRC), extended family caring (EFC), cultural pride reinforcement (CPR), and assessed regarding their use of child mental health services. RESULTS: At the multivariate level, the use of child mental health services was significantly positively associated with moderate levels of endorsement of SRC and EFC. Inversely, scores in the moderate range of CPR were associated with a reduced likelihood of child mental health service use. CONCLUSION: Parental endorsement of racial socialization parenting practices appear to play a salient role in child mental health service use among an urban African American families. Further research with larger and more representative samples should be pursued.

Prevalence and predictors of health service use among Iraqi asylum seekers in the Netherlands

BACKGROUND

A long asylum procedure is associated with higher prevalence rates of psychiatric disorders, lower quality of life, higher disability and more physical health problems. Additional knowledge about health seeking behavior is necessary to guide governments and health professionals in their policies.

OBJECTIVE

To measure service use among one of the biggest asylum seekers population in the Netherlands and to assess its relationships with predisposing and need variables (including post-migration living problems).

METHOD

Two groups were randomly selected: Group 1 (n = 143), less than 6 months and Group 2 (n = 151), more than 2 years in the Netherlands. Respondents were interviewed with fully structured, culturally validated, translated questionnaires, which contained instruments to measure psychiatric disorders, quality of life, disability, physical health and post-migration living problems. Use of preventive and curative (physical and mental) health services was measured and the relationship with predisposing and need risk factors was estimated with univariate and multivariate logistic regression analyses.

RESULTS

A long asylum procedure is not associated with higher service use, except for mental health service use and drug use. Use of mental health services is, however, low compared to the prevalence of psychiatric disorders. Low quality of perceived general health and functional disability are the most important predictors of services use. Psychopathology predicts use of a medical specialist (non-psychiatrist), but does not predict mental health service use.

CONCLUSION

A high percentage of asylum seekers with a psychiatric disorder is not getting adequate treatment. There is a mismatch between the type of health problem and the type of health service use. The various health services should work together in education, detection, referral and care in order to provide help to this group of patients.

Health risk appraisal in older people 1: are older people living alone an "at-risk" group?

BACKGROUND

In the UK, population screening for unmet need has failed to improve the health of older people. Attention is turning to interventions targeted at 'at-risk' groups. Living alone in later life is seen as a potential health risk, and older people living alone are thought to be an at-risk group worthy of further intervention.

AIM

To explore the clinical significance of living alone and the epidemiology of lone status as an at-risk category, by investigating associations between lone status and health behaviours, health status, and service use, in non-disabled older people.

DESIGN OF STUDY

Secondary analysis of baseline data from a randomised controlled trial of health risk appraisal in older people.

SETTING

Four group practices in suburban London.

METHOD

Sixty per cent of 2641 community-dwelling non-disabled people aged 65 years and over registered at a practice agreed to participate in the study; 84% of these returned completed questionnaires. A third of this group, (n = 860, 33.1%) lived alone and two-thirds (n = 1741, 66.9%) lived with someone else.

RESULTS

Those living alone were more likely to report fair or poor health, poor vision, difficulties in instrumental and basic activities of daily living, worse memory and mood, lower physical activity, poorer diet, worsening function, risk of social isolation, hazardous alcohol use, having no emergency carer, and multiple falls in the previous 12 months. After adjustment for age, sex, income, and educational attainment, living alone remained associated with multiple falls, functional impairment, poor diet, smoking status, risk of social isolation, and three self-reported chronic conditions: arthritis and/or rheumatism, glaucoma, and cataracts.

CONCLUSION

Clinicians working with independently-living older people living alone should anticipate higher levels of disease and disability in these patients, and higher health and social risks, much of which will be due to older age, lower educational status, and female sex. Living alone itself appears to be associated with higher risks of falling, and constellations of pathologies, including visual loss and joint disorders. Targeted population screening using lone status may be useful in identifying older individuals at high risk of falling.

Health risk appraisal in older people 2: the implications for clinicians and commissioners of social isolation risk in older people

BACKGROUND

Social isolation is associated with poorer health, and is seen by the World Health Organisation (WHO) as one of the major issues facing the industrialised world.

AIM

To explore the significance of social isolation in the older population for GPs and for service commissioners.

DESIGN OF STUDY

Secondary analysis of baseline data from a randomised controlled trial of health risk appraisal.

SETTING

A total of 2641 community-dwelling, non-disabled people aged 65 years and over in suburban London.

METHOD

Demographic details, social network and risk for social isolation based on the 6-item Lubben Social Network Scale, measures of depressed mood, memory problems, numbers of chronic conditions, medication use, functional ability, self-reported use of medical services.

RESULTS

More than 15% of the older age group were at risk of social isolation, and this risk increased with advancing age. In bivariate analyses risk of social isolation was associated with older age, education up to 16 years only, depressed mood and impaired memory, perceived fair or poor health, perceived difficulty with both basic and instrumental activities of daily living, diminishing functional ability, and fear of falling. Despite poorer health status, those at risk of social isolation did not appear to make greater use of medical services, nor were they at greater risk of hospital admission. Half of those who scored as at risk of social isolation lived with others. Multivariate analysis showed significant independent associations between risk of social isolation and depressed mood and living alone, and weak associations with male sex, impaired memory and perceived poor health.

CONCLUSION

The risk of social isolation is elevated in older men, older persons who live alone, persons with mood or cognitive problems, but is not associated with greater use of services. These findings would not support population screening for individuals at risk of social isolation with a view to averting service use by timely intervention. Awareness of social isolation should trigger further assessment, and consideration of interventions to alleviate social isolation, treat depression or ameliorate cognitive impairment.

Considering context, place and culture: the National Latino and Asian American Study

This paper provides a rationale for, and overview of, procedures used to develop the National Latino and Asian American Study (NLAAS). The NLAAS is nationally representative community household survey that estimates the prevalence of mental disorders and rates of mental health service utilization by Latinos and Asian Americans in the US. The central aims of the NLAAS are to: 1) describe the lifetime and 12-month prevalence of psychiatric disorders and the rates of mental health services use for Latino and Asian American populations using nationwide representative samples of Latinos and Asian Americans, 2) assess the associations among social position, environmental context, and psychosocial factors with the prevalence of psychiatric disorders and utilization rates of mental health services, and 3) compare the lifetime and 12-month prevalence of psychiatric disorders, and utilization of mental health services of Latinos and Asian Americans with national representative samples of non-Latino whites (from the National Comorbidity Study-Replication) (NCS-R) and African Americans (from the National Survey of American Life) (NSAL). This paper presents new concepts and methods utilized in the development of the NLAAS to capture and investigate ethnic, cultural and environmental considerations that are often ignored in mental health research.

The National Survey of American Life: a study of racial, ethnic and cultural influences on mental disorders and mental health

The objectives of the National Survey of American Life (NSAL) are to investigate the nature, severity, and impairment of mental disorders among national samples of the black and non-Hispanic white (n = 1,006) populations in the US. Special emphasis in the study is given to the nature of race and ethnicity within the black population by selecting and interviewing national samples of African-American (N = 3,570), and Afro-Caribbean (N = 1,623) immigrant and second and older generation populations. National multi-stage probability methods were used in generating the samples and race/ethnic matching of interviewers and respondents were used in the largely face-to-face interview, which lasted on average 2 hours and 20 minutes. The Diagnostic and Statistical Manual (DSM) IV World Mental Health Composite Interview (WHO-CIDI) was used to assess a wide range of serious mental disorders, potential risk and resilience factors, and help seeking and service use patterns. This paper provides an overview of the design of the NSAL, sample selection procedures, recruitment and training of the national interviewing team, and some of the special problems faced in interviewing ethnically and racially diverse national samples. Unique features of sample design, including special screening and listing procedures, interviewer training and supervision, and response rate outcomes are described.

Medicaid enrollment among elderly medicare beneficiaries: individual determinants, effects of state policy, and impact on service use

OBJECTIVE

To better understand factors associated with Medicaid enrollment among low-income, community-dwelling elderly persons and to examine the effect of Medicaid enrollment on the use of health care services by elderly persons, taking into account selection in program participation.

DATA SOURCES

1996 Medicare Current Beneficiary Survey (MCBS) Access to Care and Cost and Use files.

METHODS

Individual-level predictions of the probability of dual enrollment are obtained from equations that estimate jointly the residential status of Medicare beneficiaries (community versus institution) and the probability of Medicaid enrollment among community-dwelling eligible beneficiaries. Predicted values are then substituted into the service use equations, which are estimated via two-part models.

PRINCIPAL FINDINGS

Less than half of all community-dwelling elderly persons with incomes at or below 100 percent of the Federal Poverty Level (FPL) were enrolled in Medicaid in 1996. Once selective enrollment was accounted for, there was limited evidence of a dual enrollment effect on service use. Although there were no effects of state Medicaid policy variables on the probability that beneficiaries lived in the community (as opposed to nursing homes), the effects of state's Medicaid generosity in home and community-based services had a sizeable and statistically significant effect on influencing the likelihood that eligible elderly persons enrolled in Medicaid.

CONCLUSIONS

Our results provide compelling evidence that Medicaid participation can be influenced by state policy. The observation that "policy matters" provides new insights into how existing programs might reach a larger proportion of potentially eligible beneficiaries.