Intensity Of Service Use Research Articles

Long-term use of VA mental health services by older patients with substance use disorders.

The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system. In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders. Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions. Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.

Epidemiologic assessment of overmet need in mental health care.

The traditional purpose of psychiatric epidemiologic surveys has been the assessment of mental illness and, by implication, the need for care. Previous research has focused on unmet need, defined as those who meet "caseness" but do not receive care, but has rarely examined the converse. Since survey respondents receiving care but not meeting caseness have been found to represent up to one-half of mental health service users, this is a significant service delivery issue. The data are drawn from the Mental Health Supplement to the Ontario Health Survey (the Supplement), a household survey of 9,953 respondents, which used the University of Michigan's version of the Composite International Diagnostic Interview (UM-CIDI) as its diagnostic instrument. Community residents who used formal mental health services in the past year but who did not have a concurrent UM-CIDI/DSM-III-R (Diagnostic and Statistical Manual 3, revised) diagnosis were defined as "treated without CIDI disorder". Their need for care was evaluated by comparing them to "treated depressed" and "healthy" respondents, using indicators of functional impairment, vulnerability to developing disorder, and risk of relapse. The match between need and care levels was examined by comparing their type and intensity of use with those of the treated depressed. Results present strong evidence for conceptualizing need as continuous, rather than discrete. The results for the group defined as "treated without CIDI disorder" were consistently between those for the other two groups (with the "treated depressed" always showing the highest need) on all indicators as well as on a summary need index. However, their type and intensity of service use appeared to be unrelated to their level of need. Although some of the "treated without CIDI disorder" group may require preventive or follow-up treatment, the need for service for others is not as convincingly demonstrated. Outcome studies are needed to provide comparative data to describe more fully the problems experienced by this group and indicate whether treatment is helpful. In an age of fiscal restraint, when resource reallocation (rather than generation of new resources) is the likely scenario, such close examination of the fit between need and care is critical if services are to be targeted appropriately.

Misconceptions about use of case management services by the chronic mentally ill: a utilization analysis.

Records of service contacts made over a six-month period by 44 chronic mentally ill patients served by a private case management agency in Washington, D.C., were analyzed to assess the accuracy of common assumptions held by mental health professionals about appropriate staff-to-patient ratios, the relationship between age and chronicity and use of services, the intensity of service use over time, and similar beliefs. The results suggest that the optimum staff-to-patient ratio is about 1 to 15, that older patients require fewer service contacts than younger patients, that patients' chronicity is not related to their extent of service use, and that patients' frequency of service use does not change over time. Patients who received services at the agency and patients who were seen alone required more service contacts than patients who were seen in the community and patients who were accompanied at their service contacts by members of their support network.