Employment and economic outcomes of persons with mental illness and disability: The impact of the Great Recession in the United States

Objective: To examine variation in employment and economic outcomes before, during, and after the great recession by disability and mental health status. Methods: Using a sample of adults in the 1999 to 2016 National Health Interview Survey (N = 419,336), we examined changes in labor force and economic outcomes by mental health and physical disability status. We employed difference-in-differences analyses to determine whether the changes in these outcomes during and after the recession for each comparison group (those with moderate mental illness, serious psychiatric disability, or physical disability) were significantly different from the changes for persons with neither a mental illness nor a disability. Findings: While the recession impacted all groups, those with mental illnesses or physical disabilities were hardest hit. Persons with disabilities were disadvantaged on all outcomes at each period, but persons with mental illnesses were the most disadvantaged. Unemployment, poverty, and use of food stamps increased for all groups, but the increase was greatest for persons with mental health problems who also saw a more substantial decline in wage income. Conclusions and Implications for Practice: The effects of the recession persist well after the recovery period. Practitioners should be aware that although most persons with mental illnesses want to work, they face significant barriers to employment. Following economic shocks such as those brought on by the current coronavirus pandemic, interventions should focus on people who are the most vulnerable, especially those with mental health problems. Renewed focus on employment for people with mental disorders is important. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Police Brutality and Mistrust in Medical Institutions

BACKGROUND

People bring the social contexts of their lives into the medical encounter. As a social determinant of health, police brutality influences physical and mental health. However, negative experiences with institutions such as law enforcement might decrease trust in other institutions, including medical institutions. Mistrust might limit engagement with the healthcare system and affect population health. This study investigates the relationship between police brutality and medical mistrust and assesses whether it varies by race.

BASIC PROCEDURES

Data were obtained from a 2018 cross-sectional survey of adults living in urban areas in the USA (N = 4389). Medical mistrust was regressed on police brutality (experiences and appraisal of negative encounters with the police), controlling for socio-demographics, health status, and healthcare access. Means of mistrust were predicted by racial group after including interactions between police brutality and race.

MAIN FINDINGS

Respondents who had negative encounters with the police, even if they perceived these encounters to be necessary, had higher levels of medical mistrust compared to those with no negative police encounters. Police brutality increased mistrust for all racial groups.

PRINCIPAL CONCLUSIONS

Conditions outside the medical system such as experiencing police brutality impact relationships with the medical system. Given that clinicians are in a unique position of having access to firsthand information about the struggles and injustices that shape their patients' health, advocating for systemic change on behalf of their patients might build trust.

The Meaning and Predictive Value of Self-rated Mental Health among Persons with a Mental Health Problem

Self-rated health is a valid measure of health that predicts quality of life, morbidity, and mortality. Its predictive value reflects a conceptualization of health that goes beyond a traditional medical model. However, less is known about self-rated mental health (SRMH). Using data from the Medical Expenditure Panel Survey ( N = 2,547), we examine how rating your mental health as good-despite meeting criteria for a mental health problem-predicts outcomes. We found that 62% of people with a mental health problem rated their mental health positively. Persons who rated their mental health as good (compared to poor) had 30% lower odds of having a mental health problem at follow-up. Even without treatment, persons with a mental health problem did better if they perceived their mental health positively. SRMH might comprise information beyond the experience of symptoms. Understanding the unobserved information individuals incorporate into SRMH will help us improve screening and treatment interventions.

Racial/Ethnic Differences in the Use of Complementary and Alternative Medicine in US Adults With Moderate Mental Distress

OBJECTIVES

To examine the prevalence of complementary and alternative medicine (CAM) use by race/ethnicity and to identify sociodemographic and health-related factors associated with CAM use among US adults with moderate mental distress (MMD).

METHODS

We analyzed data from the 2012 National Health Interview Survey (NHIS). We used data for 6016 noninstitutionalized US adults with MMD (3492 non-Hispanic whites, 953 non-Hispanic blacks, 1078 Hispanics, 268 Asians, and 225 others consisted of American Indian, Alaska Native, and those reporting multiple races). The 2012 NHIS asks about 36 types of CAM use in the past 12 months. We constructed (1) overall, any CAM use; (2) 5 major types of CAM use; and (3) individual types of CAM use indicators. Using a cross-sectional design with complex survey techniques, we estimated race/ethnicity-specific CAM prevalence, and odds of past year CAM use by race/ethnicity, sociodemographic, and health-related factors.

RESULTS

Nearly 40% of adults with MMD used CAM in the past year compared with 32% of those without MMD ( P < .001). In adults with MMD, past year CAM use differed by race/ethnicity, ranging from 24.3% (blacks) to 44.7% (Asians) and 46.8% (others) ( P < .001). Being younger, female, living in the west, higher education, being employed, more than 4 ambulatory care visits, and functional limitations were associated with higher odds of CAM use ( P < .01).

CONCLUSIONS

Adults with MMD use CAM more frequently than those without MMD. In addition, CAM use was significantly differed by race/ethnicity in adults with MMD. This underscores the need for good patient-provider communication and suggests opportunity for dialogue about integration between conventional providers and CAM practitioners to facilitate optimal mental health care.

The Effectiveness of Screening for Obesity in Primary Care: Weighing the Evidence

In response to growing alarm about the increase in the prevalence of obesity in the United States, several organizations have recommended that physicians screen their adult patients for this condition and initiate treatment. Screening can be an effective intervention when the condition is grave and prevalent, when an accurate test exists, when effective treatment exists, when the screening program itself does not pose undue risks, and when early detection and treatment improve outcomes. This article critically reviews the evidence supporting these criteria in the case of obesity in adults. It extends previous reviews by assessing the potential impact that uncertainties in the evidence base may have on the effectiveness a screening program. It also examines the feasibility of such a program. We conclude that following the recommendation to screen all adults for obesity is unlikely to improve outcomes.

The long-term impacts of Medicaid exposure in early childhood: Evidence from the program's origin

This paper examines the long-term impact of exposure to Medicaid in early childhood on adult health and economic status. The staggered timing of Medicaid's adoption across the states created meaningful variation in cumulative exposure to Medicaid for birth cohorts that are now in adulthood. Analyses of the Panel Study of Income Dynamics suggest exposure to Medicaid in early childhood (age 0-5) is associated with statistically significant and meaningful improvements in adult health (age 25-54), and this effect is only seen in subgroups targeted by the program. Results for economic outcomes are imprecise and we are unable to come to definitive conclusions. Using separate data we find evidence of two mechanisms that could plausibly link Medicaid's introduction to long-term outcomes: contemporaneous increases in health services utilization for children and reductions in family medical debt.

Self-Reported Mental Disorders and Distress by Sexual Orientation: Results of the Minnesota College Student Health Survey

INTRODUCTION

Sexual minority college students (i.e., those not identifying as heterosexual, or those reporting same-sex sexual activity) may be at increased risk of poor mental health, given factors such as minority stress, stigma, and discrimination. Such disparities could have important implications for students' academic achievement, future health, and social functioning. This study compares reports of mental disorder diagnoses, stressful life events, and frequent mental distress across five gender-stratified sexual orientation categories.

METHODS

Data were from the 2007-2011 College Student Health Survey, which surveyed a random sample of college students (N=34,324) at 40 Minnesota institutions. Data analysis was conducted in 2013-2014. The prevalence of mental disorder diagnoses, frequent mental distress, and stressful life events were calculated for heterosexual, discordant heterosexual, gay or lesbian, bisexual, and unsure students. Logistic regression models were fit to estimate the association between sexual orientation and mental health outcomes.

RESULTS

Lesbian, gay, and bisexual students were more likely to report any mental health disorder diagnosis than were heterosexual students (p<0.05). Lesbian, gay, bisexual, and unsure students were significantly more likely to report frequent mental distress compared to heterosexual students (OR range, 1.6-2.7). All sexual minority groups, with the exception of unsure men, had significantly greater odds of experiencing two or more stressful life events (OR range, 1.3-2.8).

CONCLUSIONS

Sexual minority college students experience worse mental health than their heterosexual peers. These students may benefit from interventions that target the structural and social causes of these disparities, and individual-level interventions that consider their unique life experiences.

Disability, Health Insurance and Psychological Distress among US Adults: An Application of the Stress Process

Structural resources, including access to health insurance, are understudied in relation to the stress process. Disability increases the likelihood of mental health problems, but health insurance may moderate this relationship. We explore health insurance coverage as a moderator of the relationship between disability and psychological distress. A pooled sample from 2008-2010 (N=57,958) was obtained from the Integrated Health Interview Series. Chow tests were performed to assess insurance group differences in the association between disability and distress. Results indicated higher levels of distress associated with disability among uninsured adults compared to their peers with public or private insurance. The strength of the relationship between disability and distress was weaker for persons with public compared to private insurance. As the Affordable Care Act is implemented, decision-makers should be aware of the potential for insurance coverage, especially public, to ameliorate secondary conditions such as psychological distress among persons who report a physical disability.

Access and cost barriers to mental health care, by insurance status, 1999-2010

The cost of mental health services has always been a great barrier to accessing care for people with mental health problems. This article documents changes in insurance coverage and cost for mental health services for people with public insurance, private insurance, and no coverage. In 2009-10 people with mental health problems were more likely to have public insurance and less likely to have private insurance than in 1999-2000. Although access to specialty care remained relatively stable for people with mental illnesses, cost barriers to care increased among the uninsured and the privately insured who had serious mental illnesses. The rise in cost barriers among those with private insurance suggests that the current financing of care in the private insurance market is insufficient to alleviate cost burdens and has implications for reforms under the Affordable Care Act. People with mental health problems who are newly eligible to purchase private insurance under the act might still encounter high cost barriers to accessing care.

Health and health risks among sexual minority women: an examination of 3 subgroups

We used 2001-2010 National Health and Nutrition Examination Survey data to examine insurance status, source of routine care, cigarette and alcohol use, and self-rated health among lesbian, bisexual, and heterosexual women who have sex with women, compared with heterosexual women who do not have sex with women. We found higher risks of being uninsured among lesbian and bisexual women, worse self-rated health among bisexual women, higher alcohol use among bisexual and heterosexual women who have sex with women, and higher smoking across all subgroups.

Deployment of a mixed-mode data collection strategy does not reduce nonresponse bias in a general population health survey

OBJECTIVE

To assess nonresponse bias in a mixed-mode general population health survey.

DATA SOURCES

Secondary analysis of linked survey sample frame and administrative data, including demographic and health-related information.

STUDY DESIGN

The survey was administered by mail with telephone follow-up to nonrespondents after two mailings. To determine whether an additional mail contact or mode switch reduced nonresponse bias, we compared all respondents (N = 3,437) to respondents from each mailing and telephone respondents to the sample frame (N = 6,716).

PRINCIPAL FINDINGS

Switching modes did not minimize the under-representation of younger people, nonwhites, those with congestive heart failure, high users of office-based services, and low-utilizers of the emergency room but did reduce the over-representation of older adults.

CONCLUSIONS

Multiple contact and mixed-mode surveys may increase response rates, but they do not necessarily reduce nonresponse bias.

Sociology of health care reform: building on research and analysis to improve health care

Health reform efforts in the United States have focused on resolving some of the fundamental irrationalities of the system whereby costs and services utilization are often not linked to improved patient outcomes. Sociologists have contributed to these efforts by documenting the extent of problems and by confronting central questions around issues of accountability, reimbursement, and rationing that must be addressed in order to achieve meaningful reform that controls costs, expands access, and improves quality. Major reform rarely occurs without "paying off" powerful interests, a particularly difficult challenge in the context of a large and growing deficit. Central to achieving increased coverage and access, high quality, and cost control is change in reimbursement arrangements, increased accountability for both costs and outcomes, and criteria for rationing based on the evidence and accepted as legitimate by all stakeholders. Consensus about health reform requires trust. The traditional trust patients have in physicians provides an important base on which to build.

Agreement between self-reported and administrative race and ethnicity data among Medicaid enrollees in Minnesota

OBJECTIVE

This paper measures agreement between survey and administrative measures of race/ethnicity for Medicaid enrollees. Level of agreement and the demographic and health-related characteristics associated with misclassification on the administrative measure are examined.

DATA SOURCES

Minnesota Medicaid enrollee files matched to self-report information from a telephone/mail survey of 4,902 enrollees conducted in 2003.

STUDY DESIGN

Measures of agreement between the two measures of race/ethnicity are computed. Using logistic regression, we also assess whether misclassification of race/ethnicity on administrative files is associated with demographic factors, health status, health care utilization, or ratings of quality of health care.

DATA EXTRACTION

Race/ethnicity fields from administrative Medicaid files were extracted and merged with self-report data.

PRINCIPAL FINDINGS

The administrative data correctly classified 94 percent of cases on race/ethnicity. Persons who self-identified as Hispanic and those whose home language was English had the greater odds (compared with persons who self-identified as white and those whose home language was not English) of being misclassified in administrative data. Persons classified as unknown/other on administrative data were more likely to self-identify as white.

CONCLUSIONS

In this case study in Minnesota, researchers can be reasonably confident that the racial designations on Medicaid administrative data comport with how enrollees self-identify. Moreover, misclassification is not associated with common measures of health status, utilization, and ratings of quality of care. Further replication is recommended given variation in how race information is collected and coded by Medicaid agencies in different states.

Genetic screening for SSRI drug response among those with major depression: great promise and unseen perils

This article examines evidence for the potential benefit of genetic testing for SSRI response, as well as potential ethical and practical implications of the implementation of this test into standard psychiatric practice. We reviewed three areas of the literature: the burden of treatment-resistant and treatment-intolerant major depressive disorders, the evidence for the value of genetic testing to predict drug response, and the ethical and practical issues of genetic testing in usual care. Treatment resistance and treatment intolerance are common for persons treated with selective serotonin reuptake inhibitors (SSRIs) and are associated with both financial and quality-of-life costs. There is strong evidence from association studies that some polymorphisms are associated with SSRI response. However, no randomized trials have yet tested the efficacy of genetic tests to improve outcome in those with treatment resistance or treatment intolerance to SSRIs. Given the nonspecific nature of the test proposed, several ethical concerns are also involved with administering the genetic tests to patients. A randomized trial comparing response in those treated with standard psychiatric care and in those treated with psychiatric care tailored as a result of genetic test results should be completed before the implementation of these tests can be considered. Additionally, the ethical and practical questions concerning the tests must be addressed now, so that the potential impact of these tests on patient care can be well understood prior to adoption in standard practice.

Comparison of two within-household selection methods in a telephone survey of substance abuse and dependence

PURPOSE

Random-digit dial telephone surveys often rely on the random selection of one respondent within the household. We compared a new method of within-household selection to a standard "next birthday" approach on selected survey process measures, respondent characteristics, and substantive results.

METHODS

From October 2004 through June 2005, we conducted a survey of adults in Minnesota to obtain information about substance use and need for treatment. Control group respondents (n = 1944) were selected using the "next birthday" method, and experimental group respondents (n = 1086) were selected using a new method developed by Rizzo, Brick, and Park. We assessed group differences for survey process measures, such as the number of attempts to interview and the refusal, response, and cooperation rates. We also examined whether the groups differed in demographic factors, substance use, and mental health.

RESULTS

The experimental group had higher rates of refusal and lower response and cooperation rates. Demographic factors and most measures of substance use and mental health did not differ significantly between groups.

CONCLUSIONS

The experimental method of within-household selection developed by Rizzo and colleagues does not offer advantages over the classic "next birthday" method. Study limitations are discussed and opportunities for future research are identified.

Trends in Obesity-Related Counseling in Primary Care: 1995–2004

OBJECTIVE

We sought to ascertain whether the percentage of visits in which physicians provided obesity-related counseling services increased between 1995 and 2004.

METHOD

Data came from the 1995 to 2004 National Ambulatory Medical Care Survey, an annual national survey of visits to office-based physicians. Analyses are restricted to visits by adults to a primary care physician (PCP; general/family or internal medicine). The main outcome measure is the percentage of visits to physicians where patients were counseled about exercise, diet/nutrition or weight loss.

RESULTS

Sample sizes ranged from 9,583 to 14,071. In 2003/2004, approximately 20% of visits to PCPs included counseling for diet/nutrition, 14% for exercise, and 6% for weight loss. Approximately 24% of visits included at least one of these types of counseling. The odds of receiving counseling for any of these services were 22% lower in 2001/2002 and 18% lower in 2003/2004 compared with 1995/1996. Patients who went to the doctor for weight-related concerns or with an obesity-related diagnosis were more likely to receive counseling than the general population. Longer visits were associated with greater probability of obesity-related counseling.

CONCLUSIONS

Obesity-related counseling does not appear to be a substantial part of the services provided by physicians. Further efforts in developing interventions that can be used by physicians and demonstrating their effectiveness within clinical practice are needed.

Barriers to care among American Indians in public health care programs

OBJECTIVE

We sought to examine the extent to which reported barriers to health care services differ between American Indians (AIs) and non-Hispanic Whites (Whites).

METHODS

A statewide stratified random sample of Minnesota health care program enrollees was surveyed. Responses from AI and White adult enrollees (n=1281) and parents of child enrollees (n=572) were analyzed using logistic regression models that account for the complex sample design. Barriers examined include: financial, access, and cultural barriers, confidence/trust in providers, and discrimination.

RESULTS

Both AIs and Whites report barriers to health care access. However, a greater proportion of AIs report barriers in most categories. Among adults, AIs are more likely to report racial discrimination, cultural misunderstandings, family/work responsibilities, and transportation difficulties, whereas Whites are more likely to report being unable to see their preferred doctor. A higher proportion of adult enrollees compared with parents of child enrollees report barriers in most categories; however, differences between parents of AIs and White children are more substantial. In addition to racial discrimination and cultural misunderstandings, parents of AI children are more likely than parents of White enrollees to report limited clinic hours, lack of respect for religious beliefs, and mistrust of their child's provider as barriers.

CONCLUSIONS

Although individuals have enrolled in health care programs and have access to care, barriers to using these services remain. Significant differences between AIs and Whites involve issues of trust, respect, and discrimination. Providers must address barriers experienced by AIs to improve accessibility, acceptability, and quality of care for AI health care consumers.

What should non-US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s

Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic-related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health-care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health-care spending through independent management, starting with diagnostic procedure code or diagnostic-related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.

Increasing response rates in a survey of Medicaid enrollees: the effect of a prepaid monetary incentive and mixed modes (mail and telephone)

OBJECTIVES

We sought to evaluate the effect of pairing a mixed-mode mail and telephone methodology with a prepaid US 2.00 dollars cash incentive on response rates in a survey of Medicaid enrollees stratified by race and ethnicity.

RESEARCH DESIGN

Sampling was conducted in 2 stages. The first stage consisted of a simple random sample (SRS) of Medicaid enrollees. In the second stage, American Indian, African American, Latino, Hmong, and Somali enrollees were randomly sampled. A total of 8412 enrollees were assigned randomly to receive a mail survey with no incentive or a US 2.00 dollars bill.

RESULTS

The response rate within the SRS after the mail portion was 54% in the incentive group and 45% in the nonincentive group. Response rates increased considerably with telephone follow-ups. The incentive SRS response rate increased to 69%, and the nonincentive response rate increased to 64%. Differences between incentive conditions are more pronounced after the first mailing (P < 0.01); almost all differences remained significant (P < 0.05) after the completion of the mail mode. The inclusion of the US 2.00 dollars incentive had similar effects on response rates and cost across the different racial and ethnic strata, except for Latino enrollees.

CONCLUSIONS

A mixed-mode mail and telephone methodology is effective for increasing response rates in a Medicaid population overall and within different racial and ethnic groupings. The effectiveness of this strategy can be enhanced, in terms of response rate and cost, by including a US 2.00 dollars prepaid incentive.

Screening for depression in primary care: what do we still need to know?

The United States Preventive Services Task Force (USPSTF) recently issued the recommendation that primary care physicians screen adult patients for depression. A policy to screen primary care patients for depression has appeal as a strategy to reduce the personal and societal costs of undiagnosed and untreated depression. Such appeal may be justified if the evidence supports the screening policy in three areas: effectiveness, cost-effectiveness, and feasibility. The USPSTF recommendation leaves many issues in each of these areas unresolved and physicians are left the choice of two important program characteristics: screening instrument and screening interval. We discuss how uncertainties in the screening protocol and treatment process affect whether screening is an effective and cost-effective use of resources with respect to other health interventions. We suggest that targeting screening to groups at a higher risk for depression may lead to a more effective use of health care resources. A screening program may not be feasible even if effectiveness and cost-effectiveness are optimized. We discuss uncertainties in the USPSTF recommendation that affect the feasibility of implementing such a program in physicians' practices.

Differences between blacks and whites in the incidence of end-stage renal disease and associated risk factors

In the United States, the age-and-gender-adjusted incident rate of end-stage renal disease (ESRD) for blacks has been 4 times higher than that for whites. We analyzed patient information and medical services contained in the Medicare 5% random sample database. White (n = 977,436) and black (n = 77,800) Medicare enrollees who were at least 65 years old on January 1, 1997, were followed from 1999 to 2001. Hierarchical Cox regression models were used to estimate the relative risk of ESRD for blacks (with reference to whites) after adjustment for age and gender, socioeconomic status, special health conditions (anemia, chronic obstructive pulmonary disease, cardiovascular disease), primary causal diseases of ESRD (eg, diabetes, hypertension), diabetes care and preventive care (eg, hemoglobin A1c or lipid testing), and physician visits for primary or specialty care. The relative risk of ESRD for blacks (with reference to whites) was 3.52 (95% confidence interval [CI], 3.25-3.80) after adjustment for age and gender; 2.90 (95% CI, 2.67-3.15) after adjustment for socioeconomic status and special health conditions; and 2.11 (95% CI, 1.94-2.30) after further adjustment for primary causal diseases of ESRD, diabetes care and preventive care, and physician visits. We conclude that a higher prevalence of primary causal diseases of ESRD and lower access to diabetes care, preventive care, and primary physician visits in blacks compared with whites partially accounts for the racial difference in the incidence of ESRD in the elderly Medicare population. Public health policy should focus on improving access to care, which may lower the burden of ESRD in minority and other at-risk populations.

Racial, ethnic, socioeconomic, and access disparities in the use of preventive services among women

BACKGROUND

In this article we estimate the variations in receipt of age-appropriate preventive services among adult women between 21 and 64 years of age, by race and ethnic group, socioeconomic status, and access to health care. We also assess whether differences in access to care and socioeconomic status may explain racial and ethnic differences in the use of preventive services.

METHOD

Nationally representative data on adult women from the Medical Expenditure Panel Survey were used to estimate the effect of socioeconomic characteristics on the receipt of each preventive service. Receipt of each of four preventive services-cholesterol test, blood pressure reading, and two cancer screening tests (Papanicolaou smear, mammogram)-according to the 1996 recommendations of the U.S. Preventive Services Task Force were examined.

RESULTS

An overwhelming majority of adult women (93%) had had a blood pressure reading within the last 2 years. Eighty-four percent of women had had their cholesterol checked within the last 5 years. Seventy-five percent of women had received a mammogram and 80% received Pap tests. College education, high income, usual source of care, and health insurance consistently predicted use of preventive services. These factors also explained ethnic disparities in the receipt of preventive services between Latinas and white women.

CONCLUSIONS

The results from our study are encouraging because only a minority of women do not receive age-appropriate preventive services. However, low socioeconomic status, lack of insurance, and lack of a usual source of care represent significant barriers to preventive care for adult women.

Employing persons with serious mental illness

Data from various national surveys find that approximately half the population with mental disorders is gainfully employed across the entire range of occupations; such persons have an employment rate of about two-thirds that of the general population. More than a third of persons with serious mental illness also work, and many hold high-status positions. Among those with schizophrenia, a diagnosis associated with high impairment, only slightly more than a fifth are at work, and 12 percent are working full time. Approximately two-thirds are enrolled in federal disability insurance programs. Our analyses indicate considerable diversity of jobs among persons with various mental disorders. Most persons with mental illness want to work, and some with even the most serious mental disorders hold jobs requiring high levels of functioning. Educational attainment is the strongest predictor of employment in high-ranking occupations among both the general population and persons with mental disorders.

Are patients' office visits with physicians getting shorter?

BACKGROUND

Many believe that managed care creates pressure on physicians to increase productivity, see more patients, and spend less time with each patient.

METHODS

We used nationally representative data from the National Ambulatory Medical Care Survey (NAMCS) of the National Center for Health Statistics and the American Medical Association's Socioeconomic Monitoring System (SMS) to examine the length of office visits with physicians from 1989 through 1998. We assessed the trends for visits covered by a managed-care or other prepaid health plan (prepaid visits) and non-prepaid visits for primary and specialty care, for new and established patients, and for common and serious diagnoses.

RESULTS

Between 1989 and 1998 the number of visits to physicians' offices increased significantly from 677 million to 797 million, although the rate of visits per 100 population did not change significantly. The average duration of office visits in 1989 was 16.3 minutes according to the NAMCS and 20.4 minutes according to the SMS survey. According to both sets of data, the average duration of visits increased by between one and two minutes between 1989 and 1998. The duration of the visits increased for both prepaid and nonprepaid visits. Nonprepaid visits were consistently longer than prepaid visits, although the gap declined from 1 minute in 1989 to 0.6 minute in 1998. There was an upward trend in the length of visits for both primary and specialty care and for both new and established patients. The average length of visits remained stable or increased for patients with the most common diagnoses and for those with the most serious diagnoses.

CONCLUSIONS

Contrary to expectations, the growth of managed health care has not been associated with a reduction in the length of office visits. The observed trends cannot be explained by increases in physicians' availability, shifts in the distribution of physicians according to sex, or changes in the complexity of the case mix.

Is the substance abuse of inpatients with schizophrenia overlooked?

The utility of medical records and clinician reports for assessing substance abuse among inpatients with schizophrenia or schizoaffective disorder was assessed in a sample of 296 patients recruited from four general hospitals in New York City. Measures derived from the medical record, the discharge summary, and primary clinician reports are compared to the results of a structured diagnostic interview. Analysis of the sensitivity, specificity, positive predictive value, and overall accuracy of the nondiagnostic sources found unexpectedly high levels of detection. Discharge summaries had the lowest sensitivity when compared to the diagnostic interview, raising concern that inpatient staff and clinicians may fail to communicate substance abuse problems to outpatient providers.

Identifying risk factors and key strategies in linkage to outpatient psychiatric care

OBJECTIVE

The substantial failure of psychiatric patients to engage in outpatient specialty mental health care after an acute hospitalization at a time when managed care companies and others increasingly hold hospitals accountable for outcomes underscores the importance of identifying patients at high risk for not completing referrals. This study explored patient risk factors for not completing referrals and examined the success of several interventions targeted to achieving linkage with outpatient care.

METHOD

A clinically detailed, structured form was used in abstracting information from the medical records of 229 inpatients with a primary psychiatric diagnosis. Clinicians and staff at outpatient programs were contacted to determine whether patients completed their referrals.

RESULTS

Approximately two-thirds (65%) of the patients failed to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge. At high risk for unsuccessful linkage to outpatient care were patients with a persistent mental illness and those who had no prior public psychiatric hospitalization, were admitted involuntarily, and had longer lengths of stay. Controlling for risk factors, three clinical interventions used during the hospital stay more than tripled the odds of successful linkage to outpatient care: communication about patients' discharge plans between inpatient staff and outpatient clinicians, patients' starting outpatient programs before discharge, and family involvement during the hospital stay.

CONCLUSIONS

Effective clinical bridging strategies can be used to avoid unnecessary gaps in the delivery of psychiatric services. Incorporating these strategies into routine care would enhance continuity of care, especially for some high-risk patients.

Changing patterns of psychiatric inpatient care for children and adolescents in general hospitals, 1988-1995

OBJECTIVE

The authors examine patterns in utilization of psychiatric inpatient services by children and adolescents in general hospitals during 1988-1995.

METHOD

National Hospital Discharge Survey data were used to describe utilization patterns for children and adolescents with primary psychiatric diagnoses in general hospitals from 1988 to 1995.

RESULTS

During the study period, there was a 36% increase in hospital discharges and a 44% decline in mean length of stay, resulting in a 23% decline in the number of bed-days, from more than 3 million to about 2.5 million. The number of nonpsychotic major depressive disorders increased significantly. Discharges from public hospitals have declined, and those from proprietary hospitals have risen. Concurrently, the role of private insurance declined and the role of Medicaid increased. During the period of study, the mean and median length of stay declined most for children and adolescents who were hospitalized in private facilities and those covered by private insurance. Across the United States, the mean length of stay declined significantly; this decline was almost 60% in the West. Discharges also declined in the West, in contrast to the Midwest and the South, where they significantly increased.

CONCLUSIONS

Increased numbers of discharges and decreased length of stay may reflect evolving market forces and characteristics of hospitals. Further penetration by managed care into the public insurance system or modifications in existing Medicaid policy could have a profound impact on the availability of inpatient resources.

Patients with schizophrenia at risk for excessive antipsychotic dosing

BACKGROUND

Patient Outcomes Research Team treatment recommendations were used to investigate the relationship between patient characteristics and higher-than-recommended dosages (> 1000 chlorpromazine equivalents [CPZe]) at discharge.

METHOD

Inpatients who met the DSM-IV criteria for schizophrenia or schizoaffective disorder were recruited from 4 general hospitals. For those patients (N = 293) prescribed antipsychotics at discharge, chi-square tests and multiple regression analyses were used to assess the relationship between demographics, admission characteristics, comorbid diagnoses, and antipsychotic dosages. The relationship between clinical symptoms and antipsychotic dosage at discharge was also examined.

RESULTS

Antipsychotic dosages conformed to treatment guidelines for approximately 65% of patients; 21% received doses in excess of recommended levels. African American patients and those with a history of psychiatric hospitalization were more likely to be prescribed discharge antipsychotic doses greater than 1000 CPZe. Hospital differences in antipsychotic management were also observed. Regression analyses indicated that higher-than-recommended dosages found among African American patients could not be explained by differences in symptom levels at discharge. Patients with more thought disorder were also more likely to be prescribed antipsychotic dosages in excess of the recommended range. Compared with oral administration, depot administration increased the risk of excess dosage by a factor of 30. Controlling for method of administration reduced the impact of race to nonsignificance.

CONCLUSION

These results replicate earlier findings that minority individuals are more likely to be prescribed dosages in excess of the recommended range and suggest that this pattern is due to higher use of depot injection in African American patients. Further research should examine how patient characteristics and institutional factors influence medication use.

Utilization of specialty mental health care among persons with severe mental illness: the roles of demographics, need, insurance, and risk

OBJECTIVE

To examine the sociodemographic, need, risk, and insurance characteristics of persons with severe mental illness and the importance of these characteristics for predicting specialty mental health utilization among this group.

DATA SOURCE

The Healthcare for Communities survey, a national study that tracks alcohol, drug, and mental health services utilization. Data come from a telephone survey of adults from 60 communities across the United States, and from a supplemental geographically dispersed sample.

STUDY DESIGN

Respondents were categorized as having a severe mental disorder, other mental disorder, or no measured mental disorder. Differences among groups in sociodemographics (gender, marital status, race, education, and income), insurance coverage, need for mental health care (symptoms and perceived need), and risk indicators (suicide ideation, criminal involvement, and aggressive behavior) are examined. Measures of service use for mental health care include emergency room, inpatient, and specialty outpatient care. The importance of sociodemographics, need, insurance status, and risk indicators for specialty mental health care utilization are examined through logistic regression.

PRINCIPAL FINDINGS

The severely mentally ill in this study are disproportionately African American, unmarried, male, less educated, and have lower family incomes than those with other disorders and those with no measured mental disorders. In a 12-month period almost three-fifths of persons with severe mental illness did not receive specialty mental health care. One in five persons with severe mental illness are uninsured, and Medicare or Medicaid insures 37 percent. Persons covered by these public programs are over six times more likely to have access to specialty care than the uninsured are. Involvement in the criminal justice system also increases the probability that a person will receive care by a factor of about four, independent of level of need. The average number of outpatient visits for specialty care varies little across type of disorder, and the median number of visits (ten) is equivalent for those with a severe mental illness and those with other disorders.

CONCLUSIONS

Persons with severe mental illness have a high level of economic and social disadvantage. Barriers to care, including lack of insurance, are substantial and many do not receive specialty care. Public insurance programs are the major points of leverage for improving access, and policy interventions should be targeted to these programs. Problems of adequate care for the severely mentally ill may be exacerbated by the managed care trend to reductions in intensity of treatment.

Use of nursing homes in the care of persons with severe mental illness: 1985 to 1995

OBJECTIVE

The study examined patterns of care for persons with mental illness in nursing homes in the United States from 1985 to 1995. During that period resident populations in public mental hospitals declined, and legislation aimed at diverting psychiatric patients from nursing homes was enacted.

METHODS

Estimates of the number of current residents with a mental illness diagnosis and those with a severe mental illness were derived from the 1985 and 1995 National Nursing Home Surveys and the 1987 and 1996 Medical Expenditure Surveys. Trends by age group and changes in the mentally ill population over this period were assessed.

RESULTS

The number of nursing home residents diagnosed with dementia-related illnesses and depressive illnesses increased, but the number with schizophrenia-related diagnoses declined. The most substantial declines occurred among residents under age 65; more than 60 percent fewer had any primary psychiatric diagnosis or severe mental illness.

CONCLUSIONS

These findings suggest a reduced role for nursing homes in caring for persons with severe mental illness, especially those who are young and do not have comorbid physical conditions. Overall, it appears that nursing homes play a relatively minor role in the present system of mental health services for all but elderly persons with dementia.

Recent HIV testing among general hospital inpatients with schizophrenia: findings from four New York City sites

BACKGROUND

While widely acknowledged to be an important clinical and public health issue, HIV assessment, counseling, and testing for the seriously mentally ill has not been well studied.

OBJECTIVE

To determine what proportion and which inpatients with schizophrenia have been recently tested for HIV.

METHOD

A sample of 300 inpatients with schizophrenia were recruited from four general hospitals in New York City over a one year period. After confirmation of diagnosis with a structured interview, and elicitation of sociodemographic and drug use information, medical record review identified recent HIV testing. Bivariate and multivariate analyses were used to identify subgroups more likely to be tested.

FINDINGS

Recent HIV testing had been performed for 17% of the sample and was concentrated among those with higher documented risks. The majority of patients remain untested even in groups with direct risks, such as injection drug use, and indirect risks, such as frequent cocaine use in last year. Some evidence was found that white patients at risk may be less likely to be tested than Hispanic or African American patients.

CONCLUSIONS

Aggressive efforts are needed to improve knowledge of HIV status among acutely ill patients with schizophrenia.

Mission unfulfilled: potholes on the road to mental health parity

Managed care holds the promise of facilitating parity between general medical care and alcohol, drug, and mental health care by reducing expenditures, even while expanding benefits. Limitations in our knowledge of variations in needs and treatment standards for substance use and psychiatric illnesses make such disorders an easy target for management. Costs for behavioral health care services have been reduced at a faster pace than has been the case for general medical care costs. The most severely ill face the potential burdens of managed care as access and intensity of care become more uniform across patient populations.

Changing patterns of psychiatric inpatient care in the United States, 1988-1994

Using data from the National Hospital Discharge Survey and the Inventory of Mental Health Organizations, this article examines national trends in psychiatric inpatient care from 1988 to 1994 in general hospitals and mental hospitals. We find that discharges with a primary diagnosis of mental illness in general hospitals increased from 1.4 to 1.9 million during this period. The total increase of 1.2 million days of care in general hospitals was small relative to the reduction of 12.5 million inpatient days in mental hospitals. General hospital discharges increased most in private nonprofit hospitals and declined substantially in public hospitals. Length of stay has fallen most substantially in private nonprofit hospitals. Public programs have increasingly replaced private insurance as the major source of payment. These observations suggest that psychiatric inpatient care in general hospitals can be characterized as a process in which patients who would have been clients of public mental hospitals in a prior period replace privately insured patients who, under managed care, are largely treated in community settings. Private nonprofit general hospitals increasingly treat publicly financed patients with more severe illnesses.