County Mental Health System Research Articles

Mapping Racial/Ethnic Disparities in Youth Psychiatric Emergencies and Associations With Neighborhood Racial Composition, Child Opportunity, and Inequality

This study examined neighborhood-level associations among child opportunity, opportunity inequality, racial composition, and frequency of youth psychiatric emergency responses in the nation’s largest county mental health system. Geo-coded data on mobile crisis response (MCR) services, neighborhood opportunity, and child racial/ethnic population were extracted for youth in Los Angeles County between 2016 and 2019 and examined in descriptive and Poisson regression analyses. Black and Multiracial youth were overrepresented in MCRs relative to their county representation. Larger concentrations of child racial/ethnic-minority populations, lower levels of opportunity, and higher levels of opportunity inequality were each associated with higher frequency of MCRs at the zip code level. In adjusted multivariate analyses, Black youth population density and higher education opportunity inequality predicted higher incidence of MCR response. Findings may reflect actual racial disparities in youth mental health need and/or institutional racial biases embedded within community responses to youth behavior.

Preparing mental health professionals to work with justice involved clients: interprofessional collaborative practice paves the way

ABSTRACT Clinical social workers in county mental health systems often treat clients who are also involved with the criminal justice system. Effective treatment requires that social workers not only stabilize mental health problems but also address criminal behavior using evidence-based practices, a task they may be unprepared for. This paper presents a six-day training academy and curriculum for practitioners based on the Interprofessional Collaborative Practice (ICP) framework and competencies. Training was conducted by representatives of mental health and criminal justice fields. Evaluation ratings post training revealed significant improvements in all four ICP competency areas including interprofessional communication and treatment skills.

Reducing Mental Health Emergency Services for Children Served Through California's Full Service Partnerships.

Children's Full Service Partnerships (FSP), created through California's Mental Health Services Act of 2004 are comprehensive treatment and support programs incorporating a wraparound model designed to serve undertreated families with children who have a serious emotional disturbance and are at risk for suicide, violence, residential instability, criminal justice involvement, or involuntary hospitalization. This study investigated whether FSP programs resulted in reduced crisis-related mental health emergency services (MHES) for the children they served. Using a statewide data set for 464,880 children and youth ages 11to <18 served by California's county mental health systems between 2004 and 2012, the study compared age-related trajectories of MHES use for FSP-served children before and after treatment alongside children in usual care. Estimates were made within stratified age groups (11 to <15 and 15 to <18), utilizing propensity score adjusted random effects for each child's increasing age to control individual differences in MHES likelihood and trajectory, while controlling for age, cohort, county of service, and clinical and demographic covariates. Before treatment in FSP, FSP-served children showed higher and increasing MHES rates initially, reflecting greater severity. After FSP treatment, FSP-served children's MHES trajectory declined more rapidly than those of controls. There is strong evidence for the success of FSP's aggressive approach in reducing dangerous, increasing trajectories in MHES use. More research is needed, but key efficacious components within the program may be candidates for broader application when providing community-based, crisis-averting care for the most socially and economically vulnerable, seriously mentally ill children and youth.

The Impact of the San Diego Wildfires on a General Mental Health Population Residing in Evacuation Areas

San Diego County Mental Health system clients completed a questionnaire after the October 2007 wildfires. As compared to those not in an evacuation area, those residing in an evacuation area reported significantly more impact of the fires. Clients who evacuated were most affected, followed by those in an evacuation area who did not evacuate. Evacuation strongly impacted client-reported emotional effects of the fire, confusion about whether to evacuate, and ability to obtain medications. Gender and clinical diagnosis interacted with evacuation status for some fire impact variables. Loss of control and disruption of routine are discussed as possibly related factors.

The psychometric properties of the Illness Management and Recovery scale in a large American public mental health system

The Illness Management and Recovery (IMR) scale was created to measure recovery outcomes produced by the IMR program. However, many other mental health care programs are now designed to impact recovery-oriented outcomes, and the IMR has been identified as a potentially valuable measure of recovery-oriented mental health outcomes. The purpose of this study was to examine the psychometric properties and structural validity of the IMR clinician scale within a variety of therapeutic modalities other than IMR in a large multiethnic sample (N=10,659) of clients with mental illness from a large U.S. county mental health system. Clients completed the IMR on a single occasion. Our estimates of internal consistency were stronger than those found in previous studies (α=0.82). The scale also related to other measures of theoretically similar constructs, supporting construct and criterion validity claims. Additionally, confirmatory factor analyses supported the multidimensional representation of the IMR clinician scale. The three-factor model of illness self-management and recovery was represented by dimensions of recovery, management, and substance use. These reliable psychometric properties support the use of both the original one-factor and revised three-factor models to assess illness self-management and recovery among a broad spectrum of clients with mental illness.

Are Children Improving? Results from Outcome Measurement in a Large Mental Health System

Standardized outcome assessment was implemented in a large county mental health system. This study examines changes in children's emotional and behavioral problems after 6months of treatment and identifies factors associated with treatment improvement. Results from 3,215 youth indicated that externalizing and internalizing problems significantly decreased from intake to 6months and that ethnicity, gender, and age were associated with caregiver-reported changes in symptomatology. While there was improvement associated with entry into treatment, the magnitude of symptom reduction was small to medium and not associated with amount of care, providing only limited support for the impact of routine out-patient care.

An exploration of secondary sex ratios among women diagnosed with anxiety disorders

Theory suggests that natural selection conserved reactivity in part because highly reactive women spontaneously abort less fit conceptuses, particularly small males. Other literature argues that high reactivity manifests clinically as anxiety disorders. If true, births to women diagnosed with anxiety disorders should exhibit a low secondary sex ratio (i.e. ratio of male to female births). We explored whether births to women diagnosed with anxiety disorders exhibit a lower sex ratio than births to women diagnosed with other psychiatric disorders, or to women without mental health diagnoses. We performed a case-control comparison of the secondary sex ratios among groups of women categorized by mental health diagnosis using birth records linked to data from California County Mental Health system records. We compared sex ratios among 5994 deliveries to mothers diagnosed with anxiety disorders, 23 443 deliveries to mothers diagnosed with other psychiatric disorders and 1 099 198 'comparison' births. Although comparison births exhibited a higher sex ratio than births to women diagnosed with anxiety disorders or with other diagnoses, differences were not statistically significant. Births to African American women diagnosed with anxiety disorders, however, exhibited sex ratios significantly lower than comparison births among African Americans (OR = 0.89, P = 0.038) or births to African American women with other mental health diagnoses (OR = 0.88, P = 0.042). We found that infants born to African American women diagnosed with anxiety disorders exhibited a significantly lower secondary sex ratio than reference groups. We urge confirmatory tests of our findings and discuss implications of the reactivity/anxiety hypothesis for psychiatry, obstetrics and public health.

Obstetric complications in women with diagnosed mental illness: the relative success of California's county mental health system.

To examine disparities in serious obstetric complications and quality of obstetric care during labor and delivery for women with and without mental illness. Linked California hospital discharge (2000-2001), birth, fetal death, and county mental health system (CMHS) records. This population-based, cross-sectional study of 915,568 deliveries in California, calculated adjusted odds ratios (AORs) for obstetric complication rates for women with a mental illness diagnosis (treated and not treated in the CMHS) compared with women with no mental illness diagnosis, controlling for sociodemographic, delivery hospital type, and clinical factors. Compared with deliveries in the general non-mentally ill population, deliveries to women with mental illness stand a higher adjusted risk of obstetric complication: AOR=1.32 (95 percent confidence interval [CI]=1.25, 1.39) for women treated in the CMHS and AOR=1.72 (95 percent CI=1.66, 1.79) for women not treated in the CMHS. Mentally ill women treated in the CMHS are at lower risk than non-CMHS mentally ill women of experiencing conditions associated with suboptimal intrapartum care (postpartum hemorrhage, major puerperal infections) and inadequate prenatal care (acute pyelonephritis). Since mental disorders during pregnancy adversely affect mothers and their infants, care of the mentally ill pregnant woman by mental health and primary care providers warrants special attention.

Costs of Implementing a Computerized Prescription System in a Public Mental Health Agency

Costs of Implementing a Computerized Prescription System in a Public Mental Health Agency

Costs of Implementing a Computerized Prescription System in a Public Mental Health Agency

The objective of this case report is to inform decision makers about costs associated with adding a computerized prescription component to an existing information system in specialty mental health agencies. A computerized prescription system was implemented in four not-for-profit mental health agencies in an urban setting as part of a larger study looking at reducing racial disparities. This brief report describes the implementation costs at one agency with ten full-time-equivalent psychiatrists for which information was available on time devoted to implementation by the management information system personnel. The financial costs of the computer network hardware and software were also documented. The total initial cost was $27,607: preimplementation cost, $3,720; technology and system integration cost, $10,148; and training cost, $13,739. Annual ongoing cost was expected to be $14,725. The technology expenditure itself is not prohibitive for initial implementation as well as for ongoing support.

Abstracts

Abstracts

Feasibility of Expanding Services for Very Young Children in the Public Mental Health Setting

A quality-improvement study evaluated the feasibility of training mental health providers to provide mental health screening and relationship-based intervention to expand services for children 0 to 5 years of age in eight California county mental health systems from November 2002 to June 2003. State-level training was provided to more than 582 participants and county-level training to more than 5425 participants, including ongoing supervision. Direct services and use of collateral services were tracked. Psychiatric symptoms were screened with new Mental Health Screening and Risk Assessment tools for 388 children (mean age, 34 months). At intake and after intervention (mean of 22 visits), an index sample (93 children) were further characterized by the Diagnostic Classification for Zero to Three and DSM-IV, and parent-child relationship was characterized by the Diagnostic Classification for Zero to Three Parent-Infant Relationship Global Assessment Scale. Providers reported that 41% of their service time was directed to the parent and child together, 35% to the parent alone, and 24% to the child alone. The 93 index children and 295 children in a clinic reference sample were comparable, supporting generalizability. After intervention, Mental Health Screening and Risk Assessment scores were significantly lower. Global Assessment of Functioning scores improved (effect size, 0.35), as did the relationship (Parent-Infant Relationship Global Assessment Scale effect size, 0.16). Training mental health staff to provide treatment to infants and preschool children and families in public mental health settings is feasible and leads to an increase in numbers of children served.

Assessing Gaps Between Policy and Practice in Medicaid Disenrollment of Jail Detainees With Severe Mental Illness

Assessing Gaps Between Policy and Practice in Medicaid Disenrollment of Jail Detainees With Severe Mental Illness

Transitions between the public mental health system and jail for persons with severe mental illness: a Markov analysis

Proposed changes to the mental health care system are usually debated in terms of either health benefits or costs savings. However, because of the extensive intersection between the mental health system and the criminal justice system, changes in the organization and financing of mental health services may change the jail detention rate. We analyze jail incarcerations for felonies and non-felonies following the start of a public managed mental health care program in King County, Washington (including Seattle). We analyze unique data that tracks individuals in and out of the public mental health, Medicaid, and criminal justice systems for 1993-1998. In this manuscript we examine individuals with severe mental illness who were enrolled in the Washington state Medicaid program. The final sample size has monthly observations on 6766 unique individuals aged 18-64. We estimate Markov models of the monthly transition probabilities among living in the community with no public mental health treatment, receiving inpatient or outpatient mental health or substance abuse services, or being in jail for either a felony or non-felony charge. The transition probabilities are adjusted for demographics and policy changes that occurred during our study period. There is little evidence of any change in the jail detention rate for severely mentally ill users of the county mental health system in contrast with other SMI individuals following the public managed care program.

A Correlational Study of the Impact of Discrimination on Disposition During Hospital Emergency Services Contacts

Racial discrimination is a phenomenon that is reported to occur throughout many domains of service provision in health care and mental health care, and is a major research concern of the National Institute of Health. Many service delivery venues have received attention to address the potential presence of racial discrimination, although a form of mental health service delivery in hospital emergency rooms known as emergency services has received sparse attention. The current study is an investigation into the presence of racial discrimination and the potential impact of such discrimination in a rural Southeastern three county public mental health system. Methodological considerations of the research approach are also discussed.

Tri-ethnic variations of co-morbid substance and alcohol use disorders in schizophrenia

Objectives This study examined the differential prevalence of substance and alcohol use disorders among European Americans, African Americans, and Latinos with schizophrenia ( n = 6424) who received public mental health services in San Diego County during fiscal year 2002–2003. Methods Data were obtained from the public mental health database used by the San Diego County Mental Health System. Chi-Square analyses and stepwise logistic regression analyses were used to examine differences regarding the prevalence of substance and alcohol use among clients with schizophrenia and schizoaffective disorder, and to analyze the sociodemographic variables associated with this co-morbidity. Results Significant differences in the prevalence of diagnosed co-morbidity were found across the ethnic groups. Rates of co-morbid diagnosis among African Americans (25%) were significantly higher than those among European Americans (22%) and Latinos (19%). Logistic regression results revealed ethnicity was a significant predictor of co-morbid substance and alcohol use, as was being homeless and male. Among Latinos, language preference was also a significant predictor. Latinos who denoted English as their primary language were 1.7 times more likely to be diagnosed with co-morbid substance or alcohol use disorders than Latinos who denoted Spanish. Conclusions Among people with schizophrenia, there were significant differences in prevalence rates and predictors of diagnosed co-morbid substance and alcohol use disorders. Future research is needed to examine the relationship among language preference, level of acculturation, and subsequent diagnosing barriers for Latinos. Among African Americans, the reasons behind increased co-morbidity rates need to be examined, and homelessness should be carefully addressed among all three ethnic groups.

Special Report: Highlights of the 2004 Institute on Psychiatric Services

Special Report: Highlights of the 2004 Institute on Psychiatric Services

Cost shifting to jails after a change to managed mental health care.

To determine whether managed mental health care for Medicaid enrollees in King County, Washington, has led to indirect cost-shifting to substitute treatments, such as jails and state mental hospitals that are free goods to providers. Complete service records for 47,300 adults who used at least one of the following systems from 1993 to 1998: King County jail system, Medicaid, or the King County mental health system. Data were also obtained from the Washington State Hospital System. A quasi-experimental analysis that compares the difference in outcomes between the pre- and post-managed care periods for Medicaid enrollees compared to non-Medicaid enrollees. The outcomes-jail costs, state hospital costs, and county outpatient mental health costs-were estimated with two-part difference-in-differences models. The regressions control for person-level fixed effects on up to 66 months of data per person. Administrative data were collected from the jail, Medicaid, and mental health systems, then merged and cleaned. Additional data on costs were obtained in interviews. There is a striking increase in the probability of jail use for persons on Medicaid following the introduction of managed care. There was a significant decrease in expenditures in the county mental health system for outpatient care. Managed care led to indirect cost-shifting, probably through poor access to services, which may have led to an increased probability of jail detention.

Clinical and legal correlates of inmates with bipolar disorder at time of criminal arrest.

In an effort to determine illness factors associated with criminality among bipolar patients, we identified bipolar arrestees housed in the psychiatric division of the Los Angeles County Jail who had a history of psychiatric treatment in the Los Angeles County community mental health system. Los Angeles County's computerized management information system was utilized to retrospectively identify all inmates evaluated over a 7-month period from July 1999 to Jan. 2000 with a DSM-IV diagnosis of bipolar I disorder, their symptoms at time of arrest, and the nature of community treatment preceding arrest. Criminal history was assessed using Sheriff's Department legal records. Demographic and clinical characteristics of these inmates were compared with characteristics present in a group of hospitalized bipolar patients without a history of arrest in Los Angeles County. Of the 66 inmates identified as having a clear diagnosis of bipolar disorder with previous community treatment in the Los Angeles County Mental Health system, the majority were manic (49/66, 74.2%) and psychotic (39/66, 59%) at time of arrest. Manic arrestees were recently released from community inpatient treatment and most were not involved in outpatient treatment postdischarge. The bipolar inmates had significantly higher rates of comorbid substance abuse than did the hospitalized bipolar patients without an arrest history (75.8% [50/66]) vs. 18.5% [10/54]). The results of this study suggest that manic symptoms place bipolar patients at significant risk for criminal offending and arrest. Intensive treatment intervention by the community mental health and criminal justice system may be needed, particularly in the immediate postmanic hospitalization period, in order to prevent incarceration of patients with bipolar disorder.

Film Depicts Mother’s Search For Compassion in MH System

Film Depicts Mother’s Search For Compassion in MH System