Does managed mental health care reallocate resources to those with greater need for services?

Economics and the Transformation of the Mental Health System

Mental illnesses provide a difficult set of challenges to American health and social institutions. Those challenges have been a continuous concern of David Mechanic's over the course of his career. In this article we trace the development of modern economic and organizational structures that drive the delivery of mental health care in the early part of the twenty-first century. We show how the nature of mental disorders themselves and the treatment for addressing those illnesses pose fundamental difficulties to health care organizational and financing structures. We analyze the factors that have caused the dramatic changes in how American society has addressed mental illnesses over the past fifty years. Specifically, we note the central influence that mainstream health, income support, and disability programs have had in shaping mental health care. We argue that the interaction of the unique features of mental illnesses and changes in mainstream health and social policy led mental health care to evolve so differently from general medical care.

Mental health screening tools in correctional institutions: a systematic review

BACKGROUND

Past studies have identified poor rates of detection of mental illness among inmates. Consequently, mental health screening is a common feature to various correctional mental health strategies and best practice guidelines. However, there is little guidance to support the selection of an appropriate tool. This systematic review compared the sensitivity and specificity of mental health screening tools among adult jail or prison populations.

METHODS

A systematic review of MEDLINE and PsycINFO up to 2011, with additional studies identified from a search of reference lists. Only studies involving adult jail or prison populations, with an independent measure of mental illness, were included. Studies in forensic settings to determine fitness to stand trial or criminal responsibility were excluded. Twenty-four studies met all inclusion and exclusion criteria for the review. All articles were coded by two independent authors. Study quality was coded by the lead author.

RESULTS

Twenty-two screening tools were identified. Only six tools have replication studies: the Brief Jail Mental Health Screen (BJMHS), the Correctional Mental Health Screen for Men (CMHS-M), the Correctional Mental Health Screen for Women (CMHS-W), the England Mental Health Screen (EMHS), the Jail Screening Assessment Tool (JSAT), and the Referral Decision Scale (RDS). A descriptive summary is provided in lieu of use of meta-analytic techniques due to the lack of replication studies and methodological variations across studies.

CONCLUSIONS

The BJMHS, CMHS-M, CMHS-W, EMHS and JSAT appear to be the most promising tools. Future research should consider important contextual factors in the implementation of a screening tool that have received little attention. Randomized or quasi-randomized trials are recommended to evaluate the effectiveness of screening to improve the detection of mental illness compared to standard practices.

A comparison of scoring models for computerised mental health screening for federal prison inmates

BACKGROUND

There are high rates of mental disorder in correctional environments, so effective mental health screening is needed. Implementation of the computerised mental health screen of the Correctional Service of Canada has led to improved identification of offenders with mental health needs but with high rates of false positives.

AIMS

The goal of this study is to evaluate the use of an iterative classification tree (ICT) approach to mental health screening compared with a simple binary approach using cut-off scores on screening tools.

METHODS

A total of 504 consecutive admissions to federal prison completed the screen and were also interviewed by a mental health professional. Relationships between screening results and more extended assessment and clinical team discussion were tested.

RESULTS

The ICT was more parsimonious in identifying probable 'cases' than standard binary screening. ICT was also highly accurate at detecting mental health needs (AUC=0.87, 95% CI 0.84-0.90). The model identified 118 (23.4%) offenders as likely to need further assessment or treatment, 87% of whom were confirmed cases at clinical interview. Of the 244 (48.4%) offenders who were screened out, only 9% were clinically assessed as requiring further assessment or treatment. Standard binary screening was characterised by more false positives and a comparable false negative rate.

CONCLUSIONS

The use of ICTs to interpret screening data on the mental health of prisoners needs further evaluation in independent samples in Canada and elsewhere. This first evaluation of the application of such an approach offers the prospect of more effective and efficient use of the scarce resource of mental health services in prisons. Although not required, the use of computers can increase the ease of implementing an ICT model.

The impact of managed care on psychiatric hospitalizations and length of stay in Puerto Rico

The objective of this paper is to estimate the impact of managed care on psychiatric hospitalizations and length of stay of medically indigent residents in Puerto Rico. A quasi-experimental design and three waves of data from a random community sample were used. Results indicate that, after 2 years, managed care had minimal impact on the number of psychiatric hospitalizations; while the mean length of hospitalization decreased after implementation of managed care, this change was not significant. Based on the data in this study, the managed care initiative developed as part of health reform in Puerto Rico did not appear to affect rates of psychiatric hospitalization and produced only a nonsignificant reduction in the average length of psychiatric hospital stays. Additional research is needed to determine trends in mental health care provision in Puerto Rico based on more recent data.

Managed care and systems cost-effectiveness: treatment for depression

OBJECTIVE

The objective of this study was to assess the change in system cost-effectiveness of depression treatment after the introduction of managed care.

DATA SOURCES/STUDY SETTING

The study population consisted of adults ages 18 to 69 living in low-income areas of Puerto Rico.

STUDY DESIGN

Using a random probability sample of the population, 2 waves (1992-1993, 1993-1994) of data were collected before implementation of managed care and one wave (1996-1998) after implementation. Composite International Diagnostic Interview (CIDI)-generated depression diagnoses and Centers for Epidemiologic Studies-Depression (CES-D) scale of depressive symptoms scales were used to assess depression.

DATA COLLECTION/EXTRACTION METHODS

Effectiveness of treatment was defined by guideline standards and experts' assessment of the probability of remission resulting from treatment. Costs were measured by assigning representative prices to each treatment modality. Difference-in-difference (D-in-D) estimators were used to assess the impact of managed care on the effectiveness and costs of treating depression at the system level for the entire population.

PRINCIPAL FINDINGS

System cost-effectiveness improved slightly after the introduction of managed care, with diminished costs but no significant improvements in effectiveness.

CONCLUSION

Cost-effectiveness can be measured at the population level to assess system changes. Additional incentives and system realignments beyond utilization review and diminished treatment costs are necessary to attain a more cost-effective system of care.

Provider turnover in public sector managed mental health care

The present study examines the extent of turnover in mental health provider networks within public sector managed mental health care over a 1-year period and its association to provider and practice characteristics. Telephone interviews were conducted with a sample of mental health services providers listed the previous year in the networks of the 3 public sector managed mental health care organizations operating in Puerto Rico. Thirty-one percent of respondents had dropped out of networks. The drop-out rate was significantly associated (P < or = .05) with increasing number of years in practice and decreasing years under contract. A nonsignificant trend was observed, suggesting that providers with subspecialty training are less likely to drop out. The results may be signaling an emerging problem in public sector managed mental health care. Stability of provider networks should be monitored by state agencies contracting out mental health care.