Specialty Mental Health Services Research Articles

Diagnosis and Treatment of Depression and Anxiety in Rural and Nonrural Primary Care: National Survey Results

Diagnosis and Treatment of Depression and Anxiety in Rural and Nonrural Primary Care: National Survey Results

Socioeconomic Position Predicts Specialty Mental Health Service Use Independent of Clinical Severity: The TRAILS Study

To investigate associations between different indices of family socioeconomic position (SEP) and the use of specialty mental health services (SMHS) and whether the associations exist after adjusting for severity of mental problems. Using data from a large longitudinal study of adolescents (N = 2,149; mean age = 13.6 years [SD = 0.53, range = 12 to 15 years]; 51% girls), we assessed the relations of family SEP indices with SMHS use while accounting for severity of mental problems in logistic regression models. Multiple informants (parent, self, and teachers) assessed severity of mental health problems using the Achenbach scales. A parent questionnaire was used to assess family SEP (parents' education, parents' occupation, and family income) and SMHS use. Baseline response rate was 76%, and 96.4% of responders were reassessed at a 2.5-year follow-up visit. Baseline assessments ran from March 2001 through July 2002 and follow-up from September 2003 to December 2004. Overall, 6.7% of the total sample and 42.9% of those with mental problems accessed SMHS. Univariable analyses yielded no significant associations between SMHS and all the indices of SEP. Adjustment for the severity of mental problems resulted in substantial and statistically significant associations of indices of SEP with SMHS use. Adolescents were particularly more likely to use SMHS with increasing levels of maternal education. Compared to mothers with elementary education, those with university education were three times more likely to consult SMHS independent of severity of their offspring's mental health problems (odds ratio [OR] = 3.18, confidence interval [CI] = 1.22, 8.30). For the aggregate measure of SEP, high SEP was associated with increased use of SMHS compared with low SEP (OR = 1.63, CI = 1.04, 2.55). Higher levels of maternal education and overall SEP predict more SMHS use when the severity of mental problems was accounted for. Without correcting for the severity of mental problems, the true association between SEP and SMHS use is obscured in early adolescents.

Treatment Receipt by Veterans After a PTSD Diagnosis in PTSD, Mental Health, or General Medical Clinics

Despite the high prevalence of posttraumatic stress disorder (PTSD) among veterans treated at Department of Veterans Affairs (VA) facilities, rates of initiation of mental health treatment and persistence in treatment are unknown. This study examined outpatient treatment participation among veterans with a recent PTSD diagnosis and treatment differences according to the VA sector in which they received the diagnosis (PTSD specialty treatment program, general mental health clinic, and general medical clinic). Administrative data for 20,284 veterans who had received a diagnosis of PTSD at VA facilities were analyzed to determine rates of treatment initiation (any psychotropic prescription, an antidepressant prescription, behavioral counseling, and either a prescription or counseling) and maintenance of pharmacotherapy (at least four 30-day supplies), and counseling (at least eight visits) for the six months after diagnosis. Approximately two-thirds of the sample initiated treatment: 50% received a psychotropic medication and 39% received some counseling; 64% received either medication or counseling. About half of those given medication (54%) received at least a four-month supply, and 24% of those given counseling had at least eight sessions. Overall, 33% received minimally adequate treatment. Initiation, type, and duration varied by treatment sector: receipt of a diagnosis in a PTSD specialty program or a mental health clinic conferred small but significant benefits over receipt in a general medical clinic. Greater availability of mental health specialty services, particularly PTSD services, may be needed to ensure that veterans receive minimally adequate treatment after a PTSD diagnosis.

Disproportionate Use of Psychiatric Emergency Services by African Americans

Disproportionate Use of Psychiatric Emergency Services by African Americans

Prevalences and correlates of sleep problems among adolescents in specialty mental health services and in the community: What differs?

Aims: Knowledge of sleep problems and their relationships among adolescent psychiatric patients is limited. This study investigated whether adolescents in specialty mental health care differ in rate and correlates of sleep problems from adolescents in a community sample; 2465 adolescents from a community sample were compared with a representative clinical sample of 129 adolescent patients. Methods: Comparisons were made on frequent sleep problems according to scores on the Youth Self-Report, the Mood and Feelings Questionnaire, and instruments assessing coping styles, stresses and family functioning. Results: Sleep problems were more frequent in the clinical sample than the community sample (31.3% vs. 5%). Sleeping little and being overtired were the most common sleep problems. Sleep problems were multivariately associated with internalizing problems in both samples. Poor family functioning and distractive coping were multivariately associated with sleep problems among adolescent patients, whereas depressive symptoms were multivariately associated in community adolescents. Conclusions: Prevalences of sleep problems were high among adolescent patients. However, sleep problems may be in danger of being unnoticed in clinical practice. Clinicians should ask about such problems and be aware of possible connections with family functioning, depression and suicidality. Therapeutic interventions directed towards sleep problems should be considered.

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Following efforts made in recent years to provide effective mental health treatments based on evidence-based guidelines, a working definition was developed in the literature detailing a minimum level of "adequate mental health care" for serious mental illness. However, little is known about racial or ethnic disparities in receipt of adequate mental health care for individuals affected with serious mental illness. The objective of this study was to examine disparities among Caucasian and Hispanic youths in receipt of adequate mental health care for past-year major depressive episodes. Data for this study were drawn from the 2005 National Survey on Drug Use and Health. The study sample was composed of 1,169 Caucasian youths and 316 Hispanic youths aged 12 to 17 with past-year major depressive episodes. The percentages of youths in the sample who received adequate mental health care for past-year major depressive episodes were estimated, and the correlates of receipt of adequate mental health care were examined. Thirty-four percent of the full sample received adequate mental health care for past-year major depressive episodes, but separate analyses indicated that adequate mental health care was received by a significantly higher proportion of Caucasian youths (36%) than Hispanic youths (27%). The odds of receiving adequate mental health care for past-year major depressive episodes for Caucasians were 1.55 times that of Hispanics (p=.01). Having Medicaid or coverage via the State Children's Health Insurance Program significantly increased the odds of receiving adequate mental care for past-year major depressive episodes for both Hispanics and Caucasians. As mental health problems of adolescents from diverse racial or ethnic backgrounds become more easily identified and a larger proportion of these groups is referred to mental health treatment services, it is important to examine the degree to which treatment should be tailored to engage and retain specific racial or ethnic groups so that they will receive the minimum of adequate mental health care.

Mental Health Services Use: Baltimore Epidemiologic Catchment Area Follow-Up

To examine the patterns of previous and current mental health services use among older adults in the Baltimore Epidemiologic Catchment Area Follow-up. Examination of a recent cohort of older adults is important because patterns of utilization may have changed due to treatment advances, changes in mental healthcare services, and greater mental health awareness. A population-based longitudinal survey. Continuing participants in a study of community-dwelling adults who were living in East Baltimore in 1981. In all, 1,067 adults for whom complete data were available. Separately, and before the mental health assessments were made, participants were asked about use of health services. Cognitive status and physical health were assessed using standardized instruments. Mental disorders were assessed using the Diagnostic Interview Schedule. Compared with adults aged 40-59 years in 2004, adults aged 60 years and older were less likely to report specialty mental health services versus general medical care without a mental health component (adjusted odds ratio = 0.28, 95% confidence interval [0.14-0.56]). Multivariate models controlled for potentially influential characteristics including major depression or depression associated with recent bereavement, anxiety disorders, and past use of mental health services. Adults aged 60 years and older are approximately one third as likely to consult a specialist in mental health compared with adults aged 40-59 years even accounting for other factors associated with differential use of services. Our study strengthens evidence that the primary care remains important for the treatment of psychiatric disorders in the elderly.

Mental Health Service Use During the Transition to Adulthood for Adolescents Reported to the Child Welfare System

This study analyzed patterns of outpatient mental health service use from adolescence into early adulthood among young adults who were reported as victims of maltreatment in adolescence.Data were from the National Survey of Child and Adolescent Well-Being, a national probability study of children for whom maltreatment was investigated by the child welfare system. The sample consisted of 616 young adults aged 12 to 15 at baseline. Analysis used descriptive statistics to determine need for and use of outpatient mental health services across time. Logistic regression was used to examine predictors of use of outpatient mental health services in young adulthood.Almost half of the young adults in this sample had one or more indicators of mental health problems. There was a significant decrease in use of specialty mental health services from adolescence to young adulthood, declining from 47.6% at baseline, to 14.3% at the five- to six- year follow-up. Among young adults with mental health problems, less than a quarter used outpatient mental health services. Logistic regression results indicated that having mental health problems, having Medicaid, and being white were positively associated with use of outpatient mental health services in young adulthood.Mental health problems were prevalent among young adults who were suspected of being maltreated when they were adolescents, but only about a quarter of those in need used outpatient mental health services. Interventions to improve access to outpatient mental health services for this vulnerable population should particularly support outreach and engagement of young adults who are uninsured and from racial or ethnic minority groups with a history of involvement with the child welfare system in order to meet their unique developmental needs.

Mental Health Service Use During the Transition to Adulthood for Adolescents Reported to the Child Welfare System

This study analyzed patterns of outpatient mental health service use from adolescence into early adulthood among young adults who were reported as victims of maltreatment in adolescence. Data were from the National Survey of Child and Adolescent Well-Being, a national probability study of children for whom maltreatment was investigated by the child welfare system. The sample consisted of 616 young adults aged 12 to 15 at baseline. Analysis used descriptive statistics to determine need for and use of outpatient mental health services across time. Logistic regression was used to examine predictors of use of outpatient mental health services in young adulthood. Almost half of the young adults in this sample had one or more indicators of mental health problems. There was a significant decrease in use of specialty mental health services from adolescence to young adulthood, declining from 47.6% at baseline, to 14.3% at the five- to six- year follow-up. Among young adults with mental health problems, less than a quarter used outpatient mental health services. Logistic regression results indicated that having mental health problems, having Medicaid, and being white were positively associated with use of outpatient mental health services in young adulthood. Mental health problems were prevalent among young adults who were suspected of being maltreated when they were adolescents, but only about a quarter of those in need used outpatient mental health services. Interventions to improve access to outpatient mental health services for this vulnerable population should particularly support outreach and engagement of young adults who are uninsured and from racial or ethnic minority groups with a history of involvement with the child welfare system in order to meet their unique developmental needs.

Overrepresentation of Black Americans in Psychiatric Inpatient Care

Overrepresentation of Black Americans in Psychiatric Inpatient Care

Overrepresentation of Black Americans in Psychiatric Inpatient Care

Numerous studies have documented overrepresentation of the black population in psychiatric inpatient settings, but none have included certain important covariates or examined heterogeneity within the black population. After controlling for key social, demographic, and clinical factors, the investigators sought to determine whether blacks are overrepresented in inpatient psychiatric settings; they examined differences within the black population by separately examining the prevalence of inpatient treatment of African Americans and U.S.- and foreign-born Caribbean blacks. Secondary analysis was performed on data from two population-based household surveys, the National Survey of American Life (NSAL) and the National Comorbidity Survey Replication (NCS-R), which provided a population-based sample of 9,371 community-dwelling adults, including 3,570 African Americans, 1,621 blacks of Caribbean descent, and 4,180 non-Hispanic whites. Using logistic regression, the investigators estimated self-reported lifetime psychiatric hospitalization as a function of racial-ethnic background after controlling for sociodemographic differences and differences in lifetime counseling or therapy and psychiatric diagnosis. With controls for demographic and clinical factors, both African Americans (odds ratio [OR]=2.52, 95% confidence interval [CI]=1.91-3.33) and Caribbean blacks (OR=2.74, CI=1.98-3.82) had higher odds than whites of having a psychiatric hospitalization in their lifetime. U.S.-born Caribbean blacks had much higher odds of hospitalization (OR=5.47, CI=3.60-8.32) than whites, whereas the likelihood of hospitalization of foreign-born Caribbean blacks did not differ from that of whites (OR=.96, CI=.51-1.82). Disparities between blacks and whites in the prevalence of psychiatric inpatient treatment appear to be persistent, but global comparisons mask important heterogeneity within the black population.

Gender Differences in Veterans Health Administration Mental Health Service Use: Effects of Age and Psychiatric Diagnosis

The objective of this study was to compare gender differences in mental health disease burden and outpatient mental health utilization among veterans utilizing Veterans Health Administration (VHA) mental health services in fiscal year 1999 (FY99), after the first Gulf War and significant restructuring of VHA services. We used logistic regression to examine the relationships among gender, age, diagnostic groups, and utilization of mental health and specialty mental health services in a national sample of veterans. The sample included 782,789 veterans with at least 1 outpatient visit in the VHA in FY99 associated with a mental health or substance abuse (SA) diagnosis. Subgroup analyses were performed for 4 diagnostic categories: 1) posttraumatic stress disorder (PTSD), 2) SA disorders, 3) bipolar and psychotic disorders, and 4) mood and anxiety disorders. Younger women veterans (<35 years old) were significantly less likely and older women (> or =35) more likely to use any mental health services in comparison with their male counterparts. Similar findings were observed for younger women diagnosed with SA or mood and anxiety disorders, but not among veterans with PTSD or bipolar and psychotic disorders, among whom no there were no gender or age differences. In the case of specialized services for SA or PTSD, women younger than 55 with SA or PTSD were significantly less likely to use services than men. Women veterans underutilized specialty mental health services in relation to men but receipt of mental health care overall in FY99 varied by age and diagnosis. Examining gender differences alone, without taking other factors into account, may not provide an adequate picture of women veterans' current mental health service needs.

Public-Academic Partnerships: The Thresholds-Dartmouth Partnership and Research on Shared Decision Making

Public-Academic Partnerships: The Thresholds-Dartmouth Partnership and Research on Shared Decision Making

Use of specialty mental health services by Asian Americans with psychiatric disorders.

Research suggests that Asian Americans underutilize mental health services but an understanding of the multiple factors involved in utilization has not been examined in a nationally representative sample. The current study analyzed data from the National Latino and Asian American Study (NLAAS) and examined 368 individuals with disorders to understand utilization and what factors were related to the utilization of specialty mental health services. Significant underutilization was found for Asian Americans; moreover, underutilization was especially acute among Asian American immigrants. For U.S.-born Asian Americans, use of primary care services was significantly associated with use of mental health services, but for foreign-born Asian Americans, use of primary care services was unrelated to mental health services use. For both U.S.-born and foreign-born Asian Americans, use of alternative services appeared to significantly affect whether Asian Americans with disorders utilize mental health services, but the nature of the influence varied depending on the individual's level of English-language proficiency. These findings revealed that a major mental health disparity, the underutilization of mental health services by Asian Americans, was nuanced by use of other health-related services and immigration-related factors.

RESPECT-Mil: Feasibility of a Systems-Level Collaborative Care Approach to Depression and Post-Traumatic Stress Disorder in Military Primary Care

U.S. military ground forces report high rates of war-related traumatic stressors, posttraumatic stress disorder (PTSD), and depression following deployment in support of recent armed conflicts in Iraq and Afghanistan. Affected service members do not receive needed mental health services in most cases, and they frequently report stigma and significant structural barriers to mental health services. Improvements in primary care may help address these issues, and evidence supports the effectiveness of a systems-level collaborative care approach. To test the feasibility of systems-level collaborative care for PTSD and depression in military primary care. We named our collaborative care model "Re-Engineering Systems of Primary Care for PTSD and Depression in the Military" (RESPECT-Mil). Key elements of RESPECT-Mil care include universal primary care screening for PTSD and depression, brief standardized primary care diagnostic assessment for those who screen positive, and use of a nurse "care facilitator" to ensure continuity of care for those with unmet depression and PTSD treatment needs. The care facilitator assists primary care providers with follow-up, symptom monitoring, and treatment adjustment and enhances the primary care interface with specialty mental health services. We report assessments of feasibility of RESPECT-Mil implementation in a busy primary care clinic supporting Army units undergoing frequent Iraq, Afghanistan, and other deployments. Thirty primary care providers (family physicians, physician assistants, and nurse practitioners) were trained in the model and in the care of depression and PTSD. The clinic screened 4,159 primary care active duty patient visits: 404 screens (9.7%) were positive for depression, PTSD, or both. Sixty-nine patients participated in collaborative care for 6 weeks or longer, and the majority of these patients experienced clinically important improvement in PTSD and depression. Even although RESPECT-Mil participation was voluntary for providers, only one refused participation. No serious adverse events were noted. Collaborative care is an evidence-based approach to improving the quality of primary care treatment of anxiety and depression. Our version of collaborative care for PTSD and depression, RESPECT-Mil, is feasible, safe, and acceptable to military primary care providers and patients, and participating patients frequently showed clinical improvements. Efforts to implement and evaluate collaborative care approaches for mental disorders in populations at high risk for psychiatric complications of military service are warranted.

Pharmacologic Treatment of Posttraumatic Stress Disorder Among Privately Insured Americans

Although psychological trauma affects millions of Americans, few studies have examined treatment of posttraumatic stress disorder (PTSD) in real-world service environments. This study explored pharmacological treatment of PTSD among privately insured individuals. Data were from the MarketScan database, which compiles claims from private health insurance plans nationwide. Descriptive statistics and multivariate logistic regression were used to identify predictors of any use of a psychotropic medication and use of three medication classes: antidepressants, anxiolytics or sedative-hypnotics, and antipsychotics. Of 860,090 adult mental health care users in 2005, only 10,636 (1.2%) had a diagnosis of PTSD. Sixty percent of PTSD patients received any psychotropic medication: 74.3% of those received antidepressants, 73.7% received anxiolytics or sedative-hypnotics, and 21.3% received antipsychotics. Greater likelihood of any medication use was associated with greater use of mental health services and with several comorbid psychiatric disorders. Having a comorbid diagnosis of an indicated disorder was the most robust predictor of use of each of the three medication classes: major depressive disorder and dysthymia were most strongly associated with antidepressant use, schizophrenia and bipolar disorder were associated with antipsychotic use, and anxiety disorders were associated with use of anxiolytics or sedative-hypnotics. Psychotropic medications were frequently used in the treatment of PTSD among privately insured clients. Although use targeted specifically to PTSD and to comorbid disorders was common, substantial use appeared to be unrelated to diagnosis and may be targeted at specific symptoms rather than diagnosed illnesses. Further research is needed to determine symptom-specific responses to medications across diagnoses.

Understanding Racial/Ethnic Disparities in Youth Mental Health Services

The authors examined racial/ethnic disparities in mental health service use based on problem type (internalizing/externalizing). A diverse sample of youth in contact with public sectors of care and their families provided reports of youth's symptoms and functional impairment during an initial interview. Specialty and school-based mental health service use during the subsequent 2 years was assessed prospectively. Greater disparities in mental health service receipt were evident for internalizing problems, with non-Hispanic White youth more likely to receive services in response to internalizing symptoms than minority youth. Fewer disparities in rates of unmet need emerged for externalizing problems, but minority youth were more likely to have need for externalizing problems met and African American youth were particularly likely to receive services in response to such problems. Findings highlight the importance of considering problem type when examining racial disparities in mental health services and underscore concerns about the responsiveness of mental health services for minority youth with internalizing disorders.

The use of mental health services among young adults with emotional and behavioural problems: equal use for equal needs?

Mental health problems are highly prevalent in young adults. Despite possibilities for effective treatment, only about one-third of young adults with mental health problems seek professional help. Little knowledge exists of which groups of young adults are underusing mental health services and for what reasons. The present study examined socio-demographic inequalities in the use of mental health services by young adults, and examined whether such inequalities were attributable to differences in objective need, subjective need, predisposing or enabling factors. Cross-sectional study among the general population aged 19-32 years (2,258 respondents). A postal survey was administered including questions on socio-demographic factors and mental health service use. Data were analyzed with logistic regression analysis. South-West Netherlands. All respondents with serious internalizing and externalizing problems (n = 367). Twelve-month primary and specialty mental health services use. Only 34.6% of young adults with psychopathology had used any mental health services: 16.2% had used only primary mental health services and 18.4% had used specialty mental health services. No socio-demographic differences were found in the use of only primary mental health services. However, recipients of specialty mental health services were more often female (OR = 2.12, 95% CI = 1.14-3.96), economically inactive (OR = 3.12, 95% CI = 1.59-6.09) or students (OR = 2.38, 95% CI = 1.05-5.42) and they were less often higher educated (OR = 0.49, 95% CI = 0.25-0.97). The higher odds ratio for specialty service use among young adults who were female or economically inactive attenuated when adjusting for need for care. The other socio-demographic disparities in specialty service use did not attenuate when adjusting for need, enabling or predisposing factors. Among young adults, equal use of specialty mental health services for equal needs has not been achieved. The underserved groups of young adults oppose the traditionally underserved groups in the general population, and may inform interventions aimed at improving young people's help-seeking behaviours.

Immigrant Status, Mental Health Need, and Mental Health Service Utilization Among High-Risk Hispanic and Asian Pacific Islander Youth

This study examined youth mental health service (MHS) use as a function of family immigrant status and type of mental health need (internalizing vs. externalizing). A sample of Hispanic and Asian/Pacific Islander families (youth ages 11–18; N = 457) involved with public sectors of care provided reports of youth mental health need during an initial interview and MHS use was examined prospectively over 2 years. While externalizing need predicted specialty and school-based MHS use in the overall sample, family immigrant status moderated the association between youth need and specialty MHS use such that immigrant youth were more likely to receive services for externalizing need and less likely to receive services for internalizing need relative to non-immigrant youth.