The emotional consequences of false positive mammography: African-American women's reactions in their own words

High false positive rates associated with screening for breast cancer in the United States have an unintended psychological consequence for women (Lerman et al., 1991) that has raised concerns in recent years (Sox, 1998). This study uses inductive qualitative analysis of open-ended interviews with 45 African American women living in New York City who were part of a larger study of women and their experiences after receiving an abnormal mammogram. Themes resulting from the analyses included: inadequate provider-patient communication, anxieties exacerbated by waiting and wondering, and fears of iatrogenic effects of follow-up tests such as biopsies and repeat mammograms. While more research is needed on message-framing strategies for women entering mammographic testing and follow-up, modest changes in service delivery such as improved medical communication can help to alleviate fears and enhance trust.

Gender differences in young adolescents' exposure to violence and rates of PTSD symptomatology

Gender differences in exposure to violence and levels of PTSD symptomatology were examined in a school-based sample of 621 young adolescents. Also investigated as predictors of PTSD symptoms were cognitive coping strategies, perceived social support, and the affective experience of fear. Results support the importance of evaluating gender differences, differentiating between violence by type and location, and considering both cognitive and affective factors as predictors of PTSD symptomatology.

Women and outpatient mental health services: use by black, Hispanic, and white women in a national insured population

Factors affecting ethnic differences in women's use of outpatient mental health services were analyzed to determine whether lower use by black and Hispanic women occurred when socioeconomic and other factors are controlled. Employing the Andersen and Newman model of health use, insurance claims of 1.2 million federal employees insured by Blue Cross/Blue Shield in 1983 were analyzed to identify significant predictors of use. Results revealed that black and Hispanic women had lower probabilities and amounts of use when compared to white women even after controlling for a number of variables. Further research is needed to examine cultural and gender-related factors that may underlie ethnic differences; attitudinal factors and service system barriers are also implicated. Such findings have policy implications in the current climate of health care reform for which efforts are needed to increase access to care for ethnic minority women and other underserved populations.

Administrative update: utilization of services. I. Comparing use of public and private mental health services: the enduring barriers of race and age

Data from the NIMH-Epidemiologic Catchment Area Project were used to predict differential use of private versus public outpatient mental health services, a salient concern in integrating public and private services in market-based health care reform efforts. Having a recent psychiatric disorder, being age 25-44, female, white, of higher educational level, and unmarried increase the odds of any mental health service use. However, odds of treatment in the public sector are increased for males, African Americans, those with low educational and income levels, and odds are markedly decreased for the elderly, suggesting significant barriers to care for these mentally ill subpopulations.

Women's mental health: some directions for research

Some key issues regarding gender differences in the prevalence of mental disorders, the course of mental illness, and the use of services are reviewed, along with their diagnosis and psychopharmacologic treatment. Implications for clinical practice are examined, as are directions for future research that will ensure the presence of women's mental health as a major element in the national agenda on women's health.

Predictors of emergency room use by homeless adults in New York City: the influence of predisposing, enabling and need factors

Employing data from a 1987 shelter survey of 1260 homeless adults in New York City, multivariate models of emergency room (ER) use are developed which include an array of risk factors for visiting a hospital ER including health and mental health problems, victimization and injuries. The study's primary goal is to identify factors that predict ER use in this population. Multivariate logistic and linear regression models were tested separately for men and women predicting three outcomes: any use of the ER during the past 6 months, use of the ER for injuries vs all other reasons (given any ER use), and the number of ER visits (given any ER use). Lower alcohol dependence, health symptoms and injuries were strong predictors for both men and women; other significant predictors differed markedly by gender. Both models were highly significant and produced strikingly high risk profiles. A high prevalence of victimization and injuries underlies ER use among the homeless. Based upon the findings, we recommend expanded health and victim services as well as preventive measures. Until primary care becomes available for this population, we advise against policies that discourage ER use by the homeless.

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.

Sociodemographic and disease-related correlates of depressive morbidity among diabetic patients in Zagreb, Croatia

The magnitude of depressive morbidity as well as its significant sociodemographic and disease-related correlates were investigated in a sample of 180 adult diabetic patients attending an outpatient clinic in Zagreb, Croatia (formerly Yugoslavia) in 1989. Results using the Zung Self-Rating Depression Scale yielded a prevalence rate of 60.5% with 10% manifesting severe levels of depressive symptoms. Significant correlates of higher symptoms included older age, female gender, unmarried status, less education, the presence of diabetic complications, longer duration of the disease, more demanding diabetic regimens, and poorer adherence to the regimen. The lowest coefficient was for level of glycosylated hemoglobin (r = .04), indicating a weak relationship between diabetic control and depressive symptoms. Findings are discussed in relation to other epidemiological surveys of depression and to the deteriorating economic and political situation in Croatia. The implications of untreated depression for diabetic self-care are discussed.

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.

Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature and recommendations for research and improved service delivery

Despite dramatic increases in use of hospital emergency rooms (ERs) since the 1950s, an estimated 85% of ER visits are made for non-life-threatening reasons. Using a modified version of the Andersen and Newman model of health care utilization, this paper reviews the research literature on ER use to examine what is known about factors that influence three stages of the help-seeking process: (1) problem recognition; (2) the decision to seek help; (3) the decision to use the ER. While predisposing factors other than race are not generally significant, enabling factors such as income, insurance coverage, having a usual source of care, and geographic proximity affect use of the ER, both alone and in interaction with race and other factors. The most common reason for non-urgent ER use was 'other care not available'. In addition to the absence of primary care, non-urgent use of the ER is linked to need factors arising from socioeconomic stress, psychiatric co-morbidities, and a lack of social support. Recommendations for future studies include examining prospectively all 3 stages of decision-making leading to ER use, and considering interactive effects among predictors. Implications for service delivery are discussed, including the need to re-structure health care delivery systems to provide greater access to primary care and provide more attention to psychosocial aspects of patient care in clinical settings.

Victimization and traumatic injuries among the homeless: associations with alcohol, drug, and mental problems

Data from a 1987 survey of 1,260 homeless adults in New York City show that mental problems and substance dependence were significantly linked to beating and sexual assault among women and to several types of injury and victimization among men. The extremely high rates of victimization and injury underscore a need for greater attention to the safety and welfare of homeless people.

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.

A typology based on measures of substance abuse and mental disorder

The data of this study were derived from comprehensive interviews of 311 women and 949 men residing in the New York City public shelters for homeless adults during the summer of 1987. Interviews, guided by a 57 page interview protocol, were conducted by thoroughly trained interviewers who had worked in agencies and service systems focused on mental disorders, child abuse, substance abuse and problems of homeless people. Included in the content of the interview were seven dichotomous measures of substance use, substance abuse and mental disorder. A typology of ten groups comprised of individuals with similar profiles on the seven measures served as the independent variable. Three pairs of dependent variables were suicide attempts and current thoughts of suicide, a need for medical services reported by shelter residents and by their interviewers, and disclosure of a drug problem and a need for help in treating it. Consistently meaningful associations between group memberships and the 3 pairs of dependent variables, and 16 measures of health status in previous work, were interpreted as evidence for predictive validity of the typology.

Influence of substance abuse and mental disorders on emergency room use by homeless adults

Substance abuse and mental disorders increase the health care needs of homeless persons, whose primary source of care is often the emergency room. In this study, associations between substance abuse and mental health problems and use of emergency rooms were examined using data from a 1987 survey of 1,152 homeless adults in New York City shelters. Two-thirds (N = 767) of the sample reported using an emergency room at least once in their lives, and 27.2 percent (N = 313) reported use within the previous six months. Traumatic injury was the most frequently cited reason for the last emergency room visit. Respondents who reported psychotic ideation during the previous year or severe depressive symptoms during the previous week were much more likely to have used an emergency room within the previous six months. The preliminary findings suggest that substance abuse and mental disorders play a significant role in emergency room use by homeless adults.