Epidemiologic assessment of overmet need in mental health care

Mental Healthcare Utilization among Homeless People in the Greater Paris Area

The healthcare utilization of homeless people is generally considered insufficient, and studies often suffer from methodological bias (institutionalized vs. street samples). To adapt public health policies in France, epidemiological data on this population are scarce. The objective of this study was to analyze the use of psychiatric care by homeless people with mental health problems in the Greater Paris area and to define the factors influencing this use. The data were from the SAMENTA survey performed in 2009 with a representative random street sample of 859 homeless people from the Greater Paris area. The survey studied the use of psychiatric care (lifelong use, current follow-up, discontinuation of follow-up and treatment) and factors potentially associated with this use for people with a diagnosis of a psychotic, mood or anxiety disorder, with the diagnosis established with an original survey device. Because of our complex sampling design, we describe data for only a weighted estimated prevalence, weighted estimation of the number of people in the population (N) and unweighted total subgroup studied in the survey (n). Among 840 homeless people with useable data, 377 (N = 9762) had a psychiatric disorder. The use of whole-life care for these people may seem high, estimated at 68.7%, but few people were followed up for their disorders (18.2%); individuals with a psychotic disorder were more frequently followed up (36.5%) than others were (p < 0.05). Among those followed up (n = 86, N = 1760), 63.0% were taking medication. Access to care for these people seemed preserved, but the maintenance of care seemed problematic; indeed, among people with a lifelong whole use of care (n= 232, N = 6705), 72.3% could be considered to have discontinued care. The factors that improved lifetime health service utilization or follow-up were socio-demographic (age < 42 years, more educated), social (with social security coverage, not living in a hotel), and medical (psychotic disorder, personality disorder, suicide risk, somatic chronic illness, perception of mental suffering). Improving the care of homeless people with psychiatric disorders requires improving access to care for those isolated from the health system (in particular those living in hotels) and to guarantee continuity of care, by adapting the organization of the care system and promoting social rehabilitation.

Proportion of patients without mental disorders being treated in mental health services worldwide

BACKGROUND

Previous research suggests that many people receiving mental health treatment do not meet criteria for a mental disorder but are rather 'the worried well'.

AIMS

To examine the association of past-year mental health treatment with DSM-IV disorders.

METHOD

The World Health Organization's World Mental Health (WMH) Surveys interviewed community samples of adults in 23 countries (n = 62 305) about DSM-IV disorders and treatment in the past 12 months for problems with emotions, alcohol or drugs.

RESULTS

Roughly half (52%) of people who received treatment met criteria for a past-year DSM-IV disorder, an additional 18% for a lifetime disorder and an additional 13% for other indicators of need (multiple subthreshold disorders, recent stressors or suicidal behaviours). Dose-response associations were found between number of indicators of need and treatment.

CONCLUSIONS

The vast majority of treatment in the WMH countries goes to patients with mental disorders or other problems expected to benefit from treatment.

Homeless mentally ill in Athens area: a cross-sectional study on unmet needs and help-seeking

BACKGROUND

Homelessness, a worldwide psychosocial phenomenon, is now also prevalent in Greece, mainly in Athens area.

METHODS

The possible psychiatric morbidity related to help-seeking and the underlying factors were explored in a sample of 254 homeless people from Greater Athens area, using the Mini International Neuropsychiatric Interview (M.I.N.I.).

RESULTS

The sample was predominantly male (74%) with mean age of 51 years, being in their majority homeless for over 25 months, 34.3% of them living in rough sleeping places. Overall, 56.7% of the sample met the criteria for a current Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) psychiatric disorder with 20.8% comorbidity. Only 36.2% of the identified psychiatric cases had any recent psychiatric care, while 44.4% were taking non-prescribed medication and 20.2% have been hospitalized in the last year. On the contrary, 70% of alcohol- and drug-dependent persons have been treated in a psychiatric agency, while 60.0% of them participated in rehabilitation program the last year. Logistic regression analysis revealed that being older, more educated with longer duration of homelessness, recognizing the suffering from a psychiatric problem as well as being diagnosed as 'psychotic' increased the likelihood to seek help.

CONCLUSIONS

The vast majority of the homeless mentally ill persons were lacking any current psychiatric care. The planning of a mental health-care delivery parallel to the existing social welfare system is needed to serve the unmet mental health needs of this population.

Mental disorder, service use, and barriers to care among 500 homeless people in 3 different urban settings

OBJECTIVE

To determine the standardized rates of mental disorder, health service use and barriers to care in a representatively diverse sample of homeless adults in three different sized urban centers in British Columbia, Canada.

METHOD

Five hundred homeless adults from Vancouver, Victoria and Prince George were recruited. The MINI-International Neuropsychiatric Interview PLUS was used to determine current and lifetime rates of mental disorder, mental disorder episodes and suicidality. Health service use and barriers to care were recorded.

RESULTS

Overall, 92.8 % of participants met criteria for a current mental disorder: 82.6 % for alcohol or drug dependence, 57.3 % anxiety disorder, 31.5 % mood disorder. Over half (53.4 %) met criteria for a concurrent disorder. Only 14.9 % had seen a psychiatrist and 12.7 % a mental health team in the year prior to the survey. Most common barriers included being poorly connected to the system of care and issues related to homelessness. Mental disorder rates across sites were high, however, differences were found that reflected the composition of the samples.

CONCLUSION

Improving the mental health state of the homeless will require significant capacity for mental health and concurrent disorder programming that is tailored to the community it intends to serve. Demographic features of the population may help in directing assessments of need.

Predictors of psychiatric aftercare among formerly hospitalized adolescents

OBJECTIVE

Timely aftercare can be viewed as a patient safety imperative. In the context of decreasing inpatient length of stay (LOS) and known child psychiatry human resource challenges, we investigated time to aftercare for adolescents following psychiatric hospitalization.

METHOD

We conducted a population-based cohort study of adolescents aged 15 to 19 years with psychiatric discharge between April 1, 2002, and March 1, 2004, in Ontario, using encrypted identifiers across health administrative databases to determine time to first psychiatric aftercare with a primary care physician (PCP) or a psychiatrist within 395 days of discharge.

RESULTS

Among the 7111 adolescents discharged in the study period, 24% had aftercare with a PCP or a psychiatrist within 7 days and 49% within 30 days. High socioeconomic status (adjusted hazard ratio [AHR] 1.31; 95% CI 1.21 to 1.43, P < 0.001) and psychotic disorders (AHR 1.24; 95% CI 1.12 to 1.36, P < 0.001) were associated with greater likelihood of aftercare. Youth in the northern part of the province (AHR 0.48; 95% CI 0.32 to 0.71, P < 0.001), rural areas (AHR 0.82; 95% CI 0.76 to 0.89, P < 0.001), and with self-harm or suicide attempts (AHR 0.58; 95% CI 0.53 to 0.64, P < 0.001) and substance use disorders (AHR 0.50; 95% CI 0.44 to 0.56, P < 0.001) were less likely to receive aftercare.

CONCLUSIONS

Hospitalization is our most intensive, intrusive, and expensive psychiatric treatment setting, yet in our cohort of formerly hospitalized adolescents fewer than 50% received psychiatry-related aftercare in the month postdischarge. Innovations are necessary to address geographic inequities and improve timely access to mental health aftercare for all youth.

Comprehensive determinants of health service utilisation for mental health reasons in a Canadian catchment area

INTRODUCTION

This study sought to identify factors associated with health service utilisation by individuals with mental disorders in a Canadian catchment area.

METHODS

To be included in the study, participants had to be aged between 15 and 65 and reside in the study location. Data was collected randomly from June to December 2009 by specially trained interviewers. A comprehensive set of variables (including geospatial factors) was studied using the Andersen's behavioural health service model. Univariate, bivariate, and multivariate analyses were carried out.

RESULTS

Among 406 individuals diagnosed with mental disorders, 212 reported using a mental health service at least once in the 12 months preceding the interviews. Emotional problems and a history of violence victimisation were most strongly associated with such utilisation. Participants who were middle-aged or deemed their mental health to be poor were also more likely to seek mental healthcare. Individuals living in neighbourhoods where rental accommodations were the norm used significantly fewer health services than individuals residing in neighbourhoods where homeownership was preponderant; males were also less likely to use services than females.

CONCLUSIONS

Our study broke new ground by uncovering the impact of longstanding violence victimisation, and the proportion of homeownership on mental health service utilisation among this population. It also confirmed the prominence of some variables (gender, age, emotional problems and self-perceived mental health) as key enabling variables of health-seeking. There should be better promotion of strategies designed to change the attitudes of males and youths and to deal with violence victimisation. There is also a need for initiatives that are targeted to neighbourhoods where there is more rental housing.

Mental health service utilization among patients with severe mental disorders

In light of healthcare reforms, the study aims to assess variables associated with mental healthcare service utilization in general and in both primary and specialized care by patients with severe mental disorders (SMD, mainly schizophrenia). The study is based on a sample of 140 patients with SMD from five regions in Quebec (Canada). Variables were organized in accordance with Andersen's conceptual model into four factors: predisposing, enabling, needs, and service utilization. Secondary analyses were also conducted comparing patients who were hospitalized or used emergency rooms (H.ER-Group) with patients who did not use such services (WH.ER-Group). Accessibility of services, continuity of care, and having a case manager appear to be core variables that enable service utilization. Compared with the WH.ER-Group, the H.ER-Group used twice as many services. The study highlights the importance of developing a gamut of coordinated services, easily accessible in local networks, including case managers, family physicians, and shared-care development.

Typology of adults diagnosed with mental disorders based on socio-demographics and clinical and service use characteristics

BACKGROUND

Mental disorder is a leading cause of morbidity worldwide. Its cost and negative impact on productivity are substantial. Consequently, improving mental health-care system efficiency - especially service utilisation - is a priority. Few studies have explored the use of services by specific subgroups of persons with mental disorder; a better understanding of these individuals is key to improving service planning. This study develops a typology of individuals, diagnosed with mental disorder in a 12-month period, based on their individual characteristics and use of services within a Canadian urban catchment area of 258,000 persons served by a psychiatric hospital.

METHODS

From among the 2,443 people who took part in the survey, 406 (17%) experienced at least one episode of mental disorder (as per the Composite International Diagnostic Interview (CIDI)) in the 12 months pre-interview. These individuals were selected for cluster analysis.

RESULTS

Analysis yielded four user clusters: people who experienced mainly anxiety disorder; depressive disorder; alcohol and/or drug disorder; and multiple mental and dependence disorder. Two clusters were more closely associated with females and anxiety or depressive disorders. In the two other clusters, males were over-represented compared with the sample as a whole, namely, substance abuses with or without concomitant mental disorder. Clusters with the greatest number of mental disorders per subject used a greater number of mental health-care services. Conversely, clusters associated exclusively with dependence disorders used few services.

CONCLUSION

The study found considerable heterogeneity among socio-demographic characteristics, number of disorders, and number of health-care services used by individuals with mental or dependence disorders. Cluster analysis revealed important differences in service use with regard to gender and age. It reinforces the relevance of developing targeted programs for subgroups of individuals with mental and/or dependence disorders. Strategies aimed at changing low service users' attitude (youths and males) or instituting specialised programs for that particular clientele should be promoted. Finally, as concomitant disorders are frequent among individuals with mental disorder, psychological services and/or addiction programs must be prioritised as components of integrated services when planning treatment.

Professional service utilisation among patients with severe mental disorders

BACKGROUND

Generally, patients with serious mental disorders (SMD) are frequent users of services who generate high care-related costs. Current reforms aim to increase service integration and primary care for improved patient care and health-care efficiency. This article identifies and compares variables associated with the use by patients with SMD of services offered by psychiatrists, case managers, and general practitioners (GPs). It also compares frequent and infrequent service use.

METHOD

One hundred forty patients with SMD from five regions in Quebec, Canada, were interviewed on their use of services in the previous year. Patients were also required to complete a questionnaire on needs-assessment. In addition, data were collected from clinical records. Descriptive, bivariate, and multivariate analyses were conducted.

RESULTS

Most patients used services from psychiatrists and case managers, but no more than half consulted GPs. Most patients were followed at least by two professionals, chiefly psychiatrists and case managers. Care access, continuity of care, and total help received were the most important variables associated with the different types of professional consultation. These variables were also associated with frequent use of professional service, as compared with infrequent service use. In all, enabling factors rather than need factors were the core predictors of frequency of service utilisation by patients with SMD.

CONCLUSION

This study reveals that health care system organisation and professional practice--rather than patient need profiles--are the core predictors of professional consultation by patients with SMD. The homogeneity of our study population, i.e. mainly users with schizophrenia, recently discharged from hospital, may partly account for these results. Our findings also underscored the limited involvement of GPs in this patient population's care. As comorbidity is often associated with serious mental disorders, closer follow-up by GPs is needed. Globally, more effort should be directed at increasing shared-care initiatives, which would enhance coordination among psychiatrists, GPs, and psychosocial teams (including case managers). Finally, there is a need to increase awareness among health care providers, especially GPs, of the level of care required by patients with disabling and serious mental disorders.

Uptake of health services for common mental disorders by first-generation Turkish and Moroccan migrants in the Netherlands

Background

Migration and ethnic minority status have been associated with higher occurrence of common mental disorders (CMD), while mental health care utilisation by non-Western migrants has been reported to be low compared to the general population in Western host countries. Still, the evidence-base for this is poor. This study evaluates uptake of mental health services for CMD and psychological distress among first-generation non-Western migrants in Amsterdam, the Netherlands.

Methods

A population-based survey. First generation non-Western migrants and ethnic Dutch respondents (N = 580) participated in structured interviews in their own languages. The interview included the Composite International Diagnostic Interview (CIDI) and the Kessler psychological distress scale (K10). Uptake of services was measured by self-report. Data were analysed using weighting techniques and multivariate logistic regression.

Results

Of subjects with a CMD during six months preceding the interview, 50.9% reported care for mental problems in that period; 35.0% contacted specialised services. In relation to CMD, ethnic groups were equally likely to access specialised mental health services. In relation to psychological distress, however, Moroccan migrants reported less uptake of primary care services (OR = 0.37; 95% CI = 0.15 to 0.88).

Conclusion

About half of the ethnic Dutch, Turkish and Moroccan population in Amsterdam with CMD contact mental health services. Since the primary purpose of specialised mental health services is to treat "cases", this study provides strong indications for equal access to specialised care for these ethnic groups. The purpose of primary care services is however to treat psychological distress, so that access appears to be lower among Moroccan migrants.

The Canadian Psychiatric Association practice profile survey: I. Methods and general sample characteristics

OBJECTIVE

To describe the rationale, methodology, and general sample characteristics of the Canadian Psychiatric Association (CPA) practice profile survey, a national survey of psychiatrists and psychiatric practice.

METHOD

Mail-in interviews were sent to all Canadian psychiatrists listed in their provincial registers and to all active CPA members (total = 3628). Respondents provided general information about their professional activities for one 24-hour day and detailed information for 1 randomly selected hour. Patient information--including sociodemographics, diagnostic profiles, functioning levels, risk of harm to self or others, and disposition--was elicited for 1 patient seen during the random hour as well as for the most seriously ill patient receiving clinical services that day.

RESULTS

There was a 45.5% response rate. Questionnaires completed by nonpsychiatrists or with a large percentage of missing or incorrect data were eliminated (107 surveys), resulting in a final sample size of 1570. CPA members and those from Western Canada responded at a higher rate to the survey. The results suggest some cause for concern about future manpower shortages. Most psychiatrists practise eclectically, seeing patients across the life-span, and working in both community and institutional settings. The old and the young appear to be underserviced, compared with adults.

CONCLUSIONS

This study represents an important step forward in evaluating the profile and activities of the profession.

[Therapeutic needs in psychiatric patients: a systematic review of the literature. I. General concepts and assessment measures. Needs for services]

OBJECTIVE

In Italy, mental health care is in phase of reorganisation. In this frame the measurement of users' needs may be a useful tool in planning individualised mental health service interventions and in their evaluation. Aims of the present study are (I) to highlight the basic concepts of 'needs for care' and give a brief description of the main needs assessment tools specifically developed for psychiatric patients; (II) to review studies assessing needs for mental health services in the general population; (III) to discuss the role played by the assessment of needs in planning mental health care.

METHODS

Studies published in the international literature from January 1980 to June 1999 were reviewed. The studies were located through a computerised search of the databases MEDLINE and PsycLit; in addition, the reference lists of the studies located through the computerised search and the content of main international psychiatric journals were manually scanned in order to avoid possible omissions. Studies assessing needs for services and studies assessing needs on individual level were separately reviewed. Both groups of studies, in turn, were divided in studies assessing needs for mental health care in the general population and in psychiatric patients.

RESULTS

Although most studies on needs for services used indirect methodologies and employed quite heterogeneous experimental design, they provide at large overlapping results. In the general population, about 60%-70% of patients with anxiety, depression and other neurotic disorders and 30%-40% of psychotic patients do not receive any specialist mental health care, suggesting that the majority of subjects suffering from a psychiatric disorder do not receive the mental health care they need.

CONCLUSIONS

Unmet needs for services show a higher frequency in patients with neurotic and depressive disorders, indicating a shortage in services delivery that should be taken into account both by psychiatrists and mental health planners. Moreover, the finding that a large number of patients suffering from psychotic disorders do not receive any kind of mental health care is of particular relevance for planning mental health services, since these subjects are usually the most problematic and difficult to treat.

Psychiatric morbidity, service use, and need for care in the general population: results of The Netherlands Mental Health Survey and Incidence Study

OBJECTIVES

This study examined the use of primary health care, mental health care, and informal care services, as well as unmet care needs, by individuals with different psychiatric diagnoses.

METHODS

Data were derived from the Netherlands Mental Health Survey and Incidence Study and were based on a representative sample (n = 7147) of the general population (aged 18-64 years).

RESULTS

In a 12-month period, 33.9% of those with a psychiatric disorder used some form of care; 27.2% used primary care, and 15.3% used mental health care. Patients with mood disorders were the most likely to enlist professional care; those with alcohol- and drug-related disorders were the least likely to do so. Higher educated persons who live alone, single parents, unemployed persons, and disabled persons were more likely to use mental health care. Unmet need for professional help was reported by 16.8% (men 9.9%, women 23.9%) of those with a disorder.

CONCLUSIONS

Care use varies widely by diagnostic category. The role of general medical practitioners in treating persons with psychiatric disorders is more limited than was anticipated. Patients in categories associated with extensive use of professional care are more likely to have unmet care needs.