[Show abstract][Hide abstract] ABSTRACT: Incarceration of people with mental illness has become a major social, clinical, and economic concern, with an estimated 2.1 million incarcerations in 2007. Prior studies have primarily focused on mental illness rates among incarcerated persons. This study examined rates of and risk factors for incarceration and reincarceration, as well as short-term outcomes after incarceration, among patients in a large public mental health system.
The data set included 39,463 patient records combined with 4,544 matching incarceration records from the county jail system during fiscal year 2005-2006. Risk factors for incarceration and reincarceration were analyzed with logistic regression. Time after release from the index incarceration until receiving services was examined with survival analysis.
During the year, 11.5% of patients (N=4,544) were incarcerated. Risk factors for incarceration included prior incarcerations; co-occurring substance-related diagnoses; homelessness; schizophrenia, bipolar, or other psychotic disorder diagnoses; male gender; no Medicaid insurance; and being African American. Patients older than 45, Medicaid beneficiaries, and those from Latino, Asian, and other non-Euro-American racial-ethnic groups were less likely to be incarcerated. Risk factors for reincarceration included co-occurring substance-related diagnoses; prior incarceration; diagnosed schizophrenia or bipolar disorder; homelessness; and incarceration for three or fewer days. Patients whose first service after release from incarceration was outpatient or case management were less likely to receive subsequent emergency services or to be reincarcerated within 90 days.
Modifiable factors affecting incarceration risk include homelessness, substance abuse, lack of medical insurance, and timely receipt of outpatient or case management services after release from incarceration.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was twofold: (1) To investigate the individual- and system-level characteristics associated with high utilization of acute mental health services according to a widely-used theory of service use-Andersen's Behavioral Model of Health Service Use -in individuals enrolled in a large, public-funded mental health system; and (2) To document service utilization by high use consumers prior to a transformation of the service delivery system. We analyzed data from 10,128 individuals receiving care in a large public mental health system from fiscal years 2000-2004. Subjects with information in the database for the index year (fiscal year 2000-2001) and all of the following 3 years were included in this study. Using logistic regression, we identified predisposing, enabling, and need characteristics associated with being categorized as a single-year high use consumer (HU: >3 acute care episodes in a single year) or multiple-year HU (>3 acute care episodes in more than 1 year). Thirteen percent of the sample met the criteria for being a single-year HU and an additional 8% met the definition for multiple-year HU. Although some predisposing factors were significantly associated with an increased likelihood of being classified as a HU (younger age and female gender) relative to non-HUs, the characteristics with the strongest associations with the HU definition, when controlling for all other factors, were enabling and need factors. Homelessness was associated with 115% increase in the odds of ever being classified as a HU compared to those living independently or with family and others. Having insurance was associated with increased odds of being classified as a HU by about 19% relative to non-HUs. Attending four or more outpatient visits was an enabling factor that decreased the chances of being defined as a HU. Need factors, such as having a diagnosis of schizophrenia, bipolar disorder or other psychotic disorder or having a substance use disorder increased the likelihood of being categorized as a HU. Characteristics with the strongest association with heavy use of a public mental health system were enabling and need factors. Therefore, optimal use of public mental services may be achieved by developing and implementing interventions that address the issues of homelessness, insurance coverage, and substance use. This may be best achieved by the integration of mental health, intensive case management, and supportive housing, as well as other social services.
Administration and Policy in Mental Health and Mental Health Services Research 05/2011; 39(3):200-9. DOI:10.1007/s10488-011-0350-3 · 3.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Programs that offer alternatives to hospital-based acute psychiatric care have reported promising results of lower costs, equivalent or superior outcomes, and greater patient satisfaction. This study supplements previous research that compared the outcomes, satisfaction, and cost of hospital-based care and one such alternative program, short-term acute residential treatment (START), with an analysis of patient and staff perceptions of the treatment environments.
Patients who participated were all veterans and were randomly assigned to receive treatment in a hospital psychiatric unit (N=45) or in START (N=48). Both groups completed the Ward Atmosphere Scale (WAS), a standardized measure of treatment environment, at the time of discharge. During the study, staff members from both types of programs also completed the WAS (15 hospital staff and 75 START staff).
Both patients and staff rated the START environment more favorably than the hospital environment on five of ten WAS subscales. No differences were found in congruence between staff and participants' scores at START or the hospital. WAS profiles for patients and staff from the hospital closely matched published national norms for hospitals, whereas WAS profiles for patients and staff from START more closely resembled treatment environments recommended for the most disturbed patients (lower levels of anger and aggression and higher levels of support, problem orientation, and order and organization).
The more favorable ratings of the treatment environment at START in this study are consistent with previously published findings demonstrating the viability of the START model as an alternative to hospital-based acute psychiatric care.
[Show abstract][Hide abstract] ABSTRACT: Anxiety disorders are among the most common forms of psychiatric disorder, yet few investigations have examined the prevalence or service use of clients with anxiety disorders in the public mental health sector.
We examined demographics, clinical information, and service use in clients with anxiety disorders enrolled in San Diego County Adult and Older Adult Mental Health Services in fiscal 2002-2003.
Almost 15% of the sample had a diagnosis of an anxiety disorder based on administrative billing data. Most anxiety disorder clients had additional psychiatric diagnoses, most commonly depression. Clients with both anxiety disorders and depression were more likely than those with anxiety or depression alone to use emergency psychiatric services and outpatient services than those with depression alone. Those with anxiety disorders alone used more outpatient services than those with depression alone.
Data were taken from an administrative database.
Data indicate that anxiety disorders are not uncommon in public mental health settings and are associated with higher utilization of outpatient mental health services.
[Show abstract][Hide abstract] ABSTRACT: Reports of mental health care use by Latinos compared to Caucasians have been mixed. To the authors' knowledge, no large-scale studies have examined the effects of language on mental health service use for Latinos who prefer Spanish compared to Latinos who prefer English and to Caucasians. Language is the most frequently used proxy measure of acculturation. The authors used the administrative database of a mental health system to conduct a longitudinal examination of mental health service use among Spanish-speaking versus English-speaking Latinos and Caucasians with serious mental illness.
There were 539 Spanish-speaking Latinos, 1,144 English-speaking Latinos, and 4,638 Caucasians initiating treatment for schizophrenia, bipolar disorder, or major depression during 2001-2004. Using multivariate regressions, the authors examined the differences among the groups in the type of service first used. The authors also examined the probability of use of each of four types of mental health services and the intensity of outpatient treatment.
Spanish-speaking Latinos differed from both English-speaking Latinos and Caucasians on most measures. Compared to patients in the other groups, the Spanish-speaking Latinos were less likely to enter care through emergency or jail services and more likely to enter care through outpatient services. There were no group differences in the proportion that stayed in treatment or used inpatient hospitalization.
This study suggests that for Latinos, preferred language may be more important than ethnicity in mental health service use. Future studies comparing mental health use may need to differentiate between Spanish- and English-speaking Latinos.
American Journal of Psychiatry 09/2007; 164(8):1173-80. DOI:10.1176/appi.ajp.2007.06071239 · 12.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Administrative datasets can provide information about mental health treatment in real world settings; however, an important limitation in using these datasets is the uncertainty regarding psychiatric diagnosis. To better understand the psychiatric diagnoses, we investigated the diagnostic variability of schizophrenia and major depression in a large public mental health system. Using schizophrenia and major depression as the two comparison diagnoses, we compared the variability of diagnoses assigned to patients with one recorded diagnosis of schizophrenia or major depression. In addition, for both of these diagnoses, the diagnostic variability was compared across seven types of treatment settings. Statistical analyses were conducted using t tests for continuous data and chi-square tests for categorical data. We found that schizophrenia had greater diagnostic variability than major depression (31% vs. 43%). For both schizophrenia and major depression, variability was significantly higher in jail and the emergency psychiatric unit than in inpatient or outpatient settings. These findings demonstrate that the variability of psychiatric diagnoses recorded in the administrative dataset of a large public mental health system varies by diagnosis and by treatment setting. Further research is needed to clarify the relationship between psychiatric diagnosis, diagnostic variability and treatment setting.
Psychiatry Research 12/2006; 144(2-3):167-75. DOI:10.1016/j.psychres.2005.12.002 · 2.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A variety of alternatives to acute psychiatric hospital care have been developed over the past several decades. including San Diego's short-term acute residential treatment (START) program, now comprising a certified and accredited network of six facilities with a total of 75 beds. This study compared outcomes, patient satisfaction, and episode costs for a sample of 99 veterans who received acute care either at an inpatient unit at a Department of Veterans Affairs (VA) hospital or at a START facility.
Consenting participants were randomly assigned to one of the two treatment settings. Follow-up was conducted at two months. During the follow-up period, participants received treatment as usual. Multiple standardized measures were used to maximize validity in assessing symptoms, functioning, and quality of life.
Participants who were treated in either a hospital or the START program showed significant improvement between admission, discharge, and two-month follow-up, with few statistically significant differences between the groups in symptoms and functioning. There was some evidence that START participants had greater satisfaction with services. Mean costs for the index episode were significantly lower for START participants (65 percent lower) than for those who were treated in the hospital.
The results of this study suggest that the START model provides effective voluntary acute psychiatric care in a non-hospital-based setting at considerably lower cost. Efforts to replicate and evaluate the model at additional locations merit attention.
[Show abstract][Hide abstract] ABSTRACT: The authors examined the prevalence of and risk factors for homelessness among all patients treated for serious mental illnesses in a large public mental health system in a 1-year period. The use of public mental health services among homeless persons was also examined.
The study included 10,340 persons treated for schizophrenia, bipolar disorder, or major depression in the San Diego County Adult Mental Health Services over a 1-year period (1999-2000). Analytic methods that adjusted for potentially confounding variables were used. Multivariate logistic regression analyses were used to calculate odds ratios for the factors associated with homelessness, including age, gender, ethnicity, substance use disorder, Medicaid insurance, psychiatric diagnosis, and level of functioning. Similarly, odds ratios were computed for utilization of mental health services by homeless versus not-homeless patients.
The prevalence of homelessness was 15%. Homelessness was associated with male gender, African American ethnicity, presence of a substance use disorder, lack of Medicaid, a diagnosis of schizophrenia or bipolar disorder, and poorer functioning. Latinos and Asian Americans were less likely to be homeless. Homeless patients used more inpatient and emergency-type services and fewer outpatient-type services.
Homelessness is a serious problem among patients with severe mental illness. Interventions focusing on potentially modifiable factors such as substance use disorders and a lack of Medicaid need to be studied in this population.
American Journal of Psychiatry 03/2005; 162(2):370-6. DOI:10.1176/appi.ajp.162.2.370 · 12.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The study examined gender differences in sociodemographic, clinical, and mental health service use variables among patients with schizophrenia in a public mental health care system. Data from 1999 to 2000 for 4975 adult patients were analyzed. Women were older and more likely to be married and to have Medicaid insurance and less likely to have a diagnosis of substance abuse than men. More women were living independently, whereas more men resided in assisted living facilities or were homeless. Women were significantly more likely to have had a psychiatric hospitalization than men, which may be related to differential use of services by men and women with the worst level of functioning.
[Show abstract][Hide abstract] ABSTRACT: This study examined case management service use by ethnic group in a sample of 4,249 European-American, Latino, and African-American patients with a diagnosis of schizophrenia or schizoaffective disorder who were receiving services in the public mental health sector of San Diego County during fiscal year 1998-1999.
Data on demographic and clinical variables were obtained from the public mental health services database of the San Diego County Mental Health Department. Multivariate logistic regression analyses were used to determine the relationship between the demographic and clinical variables and use of case management services.
The ethnic composition of the sample was 64 percent European American, 20 percent Latino, and 17 percent African American. Overall, 1,100 patients (26 percent) received case management services. A disproportionately greater percentage of service use occurred among European Americans (30 percent) than among patients from ethnic minorities (19 percent for Latinos and 17 percent for African Americans). The results also indicated that Spanish-speaking Latinos underused case management services; however, the underuse was less dramatic than anticipated.
The results of this study underscore the need for continuing concern about the use of case management and other mental health services by persons from ethnic minorities.
[Show abstract][Hide abstract] ABSTRACT: Authors examined the relationship between age and use of public mental health services by adults with schizophrenia in a large mental health care system.
The study sample included 4,975 patients treated for schizophrenia in San Diego County's Adult Mental Health Services (AMHS) during fiscal year 1999-2000. They compared three age-groups: 18-44 years (young adults), 45-64 (middle-aged), and 65-or-older (elderly) on 1) the number of individuals treated for schizophrenia per 10,000 people in the county, and 2) the use of six different types of public mental health services, including hospitalization, emergency psychiatric unit, crisis house, outpatient clinic, day treatment, and case management.
Elderly patients with schizophrenia were underrepresented among AMHS users with a diagnosis of schizophrenia. The use of hospitalization, emergency room, crisis house, and day treatment was highest among young-adult patients and decreased with age. Outpatient treatment use was similar for young-adult and middle-aged patients and lower for elderly patients. The only type of service use that seemed to increase with age was case management. Even after controlling for gender, ethnicity, living situation, substance use disorder, and insurance status, most of the above-mentioned age-related differences in service use persisted.
Among patients with schizophrenia in a public mental health system, old age was associated with significantly lower use of all mental health services except case management. Research is needed to explore reasons for this differential use of services across age-groups.
American Journal of Geriatric Psychiatry 09/2003; 11(5):525-33. DOI:10.1097/00019442-200309000-00007 · 4.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Considerable attention has been given to the appropriateness of mental and medical health care provided to residents of certain assisted living facilities specialized for the severely mentally ill. However, there exists little objective evidence regarding the level of services provided by these facilities in general.
To compare the use of mental and medical health services among persons with schizophrenia who were residing in assisted living facilities compared to those received by patients living independently and those who were homeless.
Medicaid claims were combined with person level data on living situation and psychological and social functioning for 1998-2000. Regression models were used to analyze whether living in a board-and-care facility was related to use of outpatient mental health services including case management, therapy, crisis stabilization, medication supervision, day treatment, and drug treatment, the probability of acute psychiatric hospitalization, the probability of hospitalization for physical health, and costs.
Residents of board-and-care facilities had greater use of outpatient mental health services and lower rates of psychiatric and medical hospitalization. Pharmacy costs and total health care costs were highest in assisted living.
Our data was observational, and selection processes related to illness severity likely affect living arrangement. Our analysis suggests that assisted living was related to greater use of outpatient mental health services and lower rates of hospitalization.
Assisted living facilities may provide a suitable environment though which to provide outpatient mental health services. Policy makers interested in reducing homelessness through interventions might consider subsidizing these facilities.
Research studies should be designed to evaluate characteristics of assisted living facilities that lead to improved function and outcomes among residents.
The Journal of Mental Health Policy and Economics 07/2003; 6(2):59-65. · 0.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The study compared the demographic and diagnostic characteristics of clients and the outcomes of treatment in five short-term acute residential treatment programs and two acute hospital-based psychiatric programs.
A total of 368 clients in the short-term acute residential treatment programs and 186 clients in the psychiatric hospital programs participated in an observational study. The study used a repeated-measures design and assessed participants on multiple standardized measures of symptoms and functioning at admission, discharge, and four-month follow-up. Comparisons between the two groups were conducted separately by diagnostic category. Measures included the Brief Symptom Inventory, the Behavior and Symptom Identification Scale-32, the Medical Outcomes Short-Form-36, and the Client Satisfaction Questionnaire-8.
The two types of programs admit persons with similar levels of acute distress who have comparable levels of improvement at discharge and an equivalent degree of short-term stability of treatment gains. Costs of treatment episodes were considerably lower for the short-term residential programs, and client satisfaction with the two types of programs was comparable.
Short-term acute residential treatment is a less costly yet similarly effective alternative to psychiatric hospitalization for many voluntary adult patients.
[Show abstract][Hide abstract] ABSTRACT: The authors describe two psychosocially oriented community residential facilities for patients with persistent and severe mental disorders and multiple failures at community tenure, and they report a retrospective study designed to evaluate treatment outcomes of program residents.
The study employed a retrospective single-group repeated-measures design to evaluate 104 patients who completed the one-year follow-up. One-year mean number of admissions to and days in a hospital or crisis center during the two years before program entry were compared with mean admissions and days for the follow-up year; employment status, living status, and Global Assessment of Functioning (GAF) Scale scores at program entry and at one-year follow-up were also compared. Thirteen sociodemographic and clinical variables were individually tested for association with outcome.
Hospital and crisis center admissions and days were significantly reduced during the follow-up year. At one-year follow-up, a significantly greater proportion of patients were employed and living independently, and fewer were homeless. GAF scores were significantly higher. No significant correlations between outcome and sociodemographic and clinical variables were found.
Despite design limitations of the study, the findings suggest that psychosocial residential treatment models can offer cost-effective and clinically efficacious care to persistently mentally ill patients.
Hospital & community psychiatry 03/1994; 45(2):152-5. DOI:10.1176/ps.45.2.152