Economic predictors of mental health service utilization: A time-series analysis

This research was designed to understand the relationships between economic indicators and mental health service utilization. Six monthly and three quarterly time-series analyses were done to assess the time-dependent association between three state-level economic indices and two measures of mental health service utilization. Consistent with the existing literature, increases in manufacturing employment were inversely related to both first admissions in state hospitals and case openings in community outpatient facilities. Labor force participation was also inversely related to first admissions to state hospitals. No relationship was found between service employment and either of the mental health service use indices. The specific findings suggest that two processes may be operating in the relationship of labor force participation and manufacturing employment with mental health service utilization. Some of the findings suggest a "crisis" process, in which service use increases rapidly following an economic stressor, whereas other findings suggest a more insidious process, in which economic stressors slowly weaken the mental health of the community and eventually lead to increased mental health service use. These results can be used to better inform social policy and preventive interventions by highlighting the human costs of changes in economic well-being. The need for more ecological research is discussed.     

Factors contributing to the utilization of mental health services in a rural setting

The purpose of this study was to examine if age, attitudes toward help-seeking, education, and sex were related to previous or intended future mental health utilization in a rural population. Data were collected via a mail survey from 438 adults. Regression analyses suggested that positive attitudes toward help-seeking, being female, and being younger were significantly related to both previous and intended future mental health service utilization. In addition, prior mental health use was significantly related to whether one would seek out mental health services in the future, Implications for mental health practitioners in rural settings are addressed, and limitations of the study discussed.     

“Like Drawing Into Sand”: Acceptability,Feasibility, and Appropriateness of a New e‐Mental Health Resource for Service Providers Working With Aboriginal and Torres Strait Islander People

Cross‐cultural considerations and difficulties recruiting and retaining skilled workers in rural and remote regions may contribute to poorer service use for Aboriginal and Torres Strait Islander people. However, electronic resources may provide the opportunity for remote workforces to deliver structured, evidence‐based, culturally appropriate treatments with limited training burden. The aim was to develop and determine the acceptability, feasibility, and appropriateness of a new e‐mental health resource (the Australian Integrated Mental Health Initiative [AIMhi] Stay Strong App) for service providers working with Aboriginal and Torres Strait Islander people in the Northern Territory. Eleven semi‐structured interviews were conducted with 15 service providers and managers from a range of rural and remote primary health care service settings in the Northern Territory. All participants were given the resource to trial for at least 1 month before being interviewed about perceived barriers and enablers, acceptability, and feasibility. Thematic analysis revealed support for the acceptability, feasibility, and appropriateness of the resource among service providers. Major themes identified included acceptability, building relationships, broad applicability, training recommendations, integration with existing systems, and constraints to implementation. This is one of the first studies to explore the acceptability of e‐mental health approaches for Aboriginal people among the remote health workforce. It is likely that e‐mental health interventions, such as the AIMhi Stay Strong App will assist services to deliver evidence‐based, structured interventions to improve well‐being for Aboriginal and Torres Strait Islander clients.     

Homeless Youths and Young Adults in Los Angeles: Prevalence of Mental Health Problems and the Relationship Between Mental Health and Substance Abuse Disorders

Although understanding of the subsistence patterns, service utilization, and HIV-risk behaviors of homeless youths and young adults is increasing, relatively little is known about the epidemiology of mental health problems in this group or the relationships between mental health problems and substance use. This study measured symptoms of depression, low self-esteem, ADHD, suicidality, self-injurious behavior (SIB), and drug and alcohol use disorder in a sample of homeless youth and young adults living in Hollywood, CA. Results indicated extremely high prevalences of mental health problems, as compared with corresponding rates of mental health problems found among housed youths in previous studies. Prevalence of mental health problems differed by age and ethnicity. African Americans were at lower risk of suicidal thoughts and SIB than were those of other ethnicities. Older respondents and females were at increased risk of depressive symptoms, and younger respondents were at increased risk of SIB. Previous history of sexual abuse and/or assault was associated with increased risk of suicidality and SIB. Risk factors for drug abuse disorder included ethnicity other than African American, homelessness for 1 year or more, suicidality, SIB, depressive symptoms, and low self-esteem. Risk factors for alcohol abuse disorder included male gender, white ethnicity, homelessness for 1 year or more, suicidality, and SIB. Extremely high rates of mental health problems and substance abuse disorders in this sample suggest the need for street-based and nontraditional mental health services targeted toward these youths and young adults.     

Let's Ask the Homeless People Themselves: A Needs Assessment Based on a Probability Sample of Adults

A probability sample of 301 homeless adults from Buffalo, NY, was followed over 6 months to document the utilization of a variety of community services, examine services desired, and identify factors associated with service utilization, preference, and satisfaction. The following needs were all rated as at least equally important as the need for affordable housing: safety, education, transportation, medical/dental treatment, and job training/placement (most of these needs were also rated as difficult to obtain). Needs for formal mental health and substance abuse services were rated as relatively unimportant and easy to obtain, and for those who actually used them, respondents were often dissatisfied with them. Of 16 predictor variables examined in multivariate analyses, several showed consistent relationships with subsequent service use, preference, and satisfaction. Younger adults, persons of color, those with dependent children, and persons having fewer social supports reported less service utilization, less satisfaction with services received, different perceived needs for particular services, and/or greater difficulty obtaining services.     

Applying Utilization Management Principles to a Comprehensive Service System for Children with Emotional and Behavioral Disorders and Their Families: A Feasibility Study

The Comprehensive Services Act for At Risk Youth and Families of Virginia (CSA), is a service, funding, and organizational reform initiative designed to improve the provision of child centered and family focused services within a community setting. We conducted this study in order to assess the feasibility of applying utilization management principles to the CSA in order to improve the appropriateness, quality, and cost effectiveness of this service delivery system. Data were gathered through focus groups, surveys, clinical profiling, and analysis of costs, and service utilization. While overall program costs increased since inception of the program, the costs per child served rose less than the rate of inflation. CSA appeared to be serving children with a high degree of emotional and behavioral difficulties. There was considerable variation among localities in placement patterns. A majority of survey and focus group respondents were willing to consider the application of utilization management principles to the CSA as long as decision making remained within localities. We concluded that there is a constructive role for utilization management approaches to improve the appropriateness and quality of services as well as enhancing efficiency in child mental health.     

Multiple-family group treatment of outpatients with schizophrenia: impact on service utilization

The impact of multiple-family group treatment (MFGT) on outpatient and inpatient mental health service utilization of 97 persons with schizophrenia was investigated. Participants were randomly assigned to standard care (n = 44) or standard care plus MFGT (n = 53). Service use for a year prior to randomization, the 2-year study period, and a 1-year follow-up were examined. Relative to standard care participants, the MFGT group had reduced community hospitalization during year 1 of the intervention and reduced state hospitalization at follow-up. During the intervention period, MFGT participants demonstrated a significant increase in outpatient utilization as a direct consequence of the intervention. However, when service use was summed across 3 years post-randomization, no group differences were observed. Results suggest that implementation of MFGT in a community mental health setting reduces inpatient service at specific time periods, without significantly increasing outpatient service utilization. These findings add to other outcomes from this study that demonstrate decreased psychiatric symptoms and caregiver distress.     

Sexual assault history and use of health and mental health services

A history of sexual assault may be associated with increased current use of mental health and medical services because of the psychologically and physically disruptive consequences of assault. To test this hypothesis, we estimated rates of mental health and medical services use among 2560 randomly selected community residents, 343 of whom had been sexually assaulted. Sexual assault was associated with seeking both forms of care. Controls for demographic variables, psychiatric diagnosis, health status, and insurance suggested that assault increases use indirectly, through poor mental and physical health. Uninsured, assaulted respondents were especially likely to consult medical providers. Respondents assaulted during childhood were particularly likely to seek mental health care. Assault was more common among mental health service users than nonusers, and among women using medical services compared to female nonpatients. The high prevalence of assault among service users underscores the need for providers to recognize and treat sexual assault-related problems.     

The Impact of Couple Therapy on Service Utilization among Military Veterans: The Moderating Roles of Pretreatment Service Utilization and Premature Termination

Couple therapy reduces relational and individual distress and may affect utilization of other health services, particularly among higher service utilizers. Although average decreases in service utilization are predicted among recipients of couple therapy, low utilizers of services may appropriately increase use. The relationship between couple therapy and service utilization was examined among a sample of 179 U.S. military veterans who received treatment in Veterans Affairs (VA) specialty couple therapy clinics. Consistent with hypotheses, overall mental and physical health visits decreased from the 12 months preceding couple therapy to the 12 months following treatment. Moderator analyses showed that decreases were greatest among individuals who were rated by their therapist as having completed a full course of couple therapy, suggesting that change was attributable to intervention. Pretreatment service utilization also moderated observed change—higher utilizers’ use of services decreased substantially, whereas lower utilizers’ slightly increased. Cost analyses revealed that the estimated per person mean cost in our sample decreased by $930.33 in the year following compared to the year prior to couple therapy, as per 2008 VA cost data. As service utilization data were only available for one partner and only for 1 year posttherapy, the true magnitude of this effect may be underestimated. Our findings are relevant to policy makers as they demonstrate that couple therapy reduces average service utilization and associated costs and addresses calls for analyses of cost effectiveness of systemic interventions.     

Lesbians and their sisters as a control group: demographic and mental health factors

Lesbians and their heterosexual sisters were compared on demographic variables and mental health subscales, so that the feasibility of using heterosexual sisters as a control group for lesbians could be investigated. Lesbians were significantly more educated, more likely to live in urban areas, and more geographically mobile than their heterosexual sisters. Heterosexual sisters were more likely than lesbians to be married and homemakers, to have children, and to identify with a formal religion. There was no difference in mental health, but lesbians had higher self-esteem. When all respondents were included, bisexual women had significantly poorer mental health than did lesbians and heterosexual women. This is the first study to use sisters as a control group in lesbian research.     

Family Support and Mental Health Service Use Among Suicidal Adolescents

Despite the fact that multiple evidence-based treatments exist for suicidal adolescents, these youth are unlikely to engage in mental health treatment. While family members can be influential in connecting adolescents to mental health care, suicidal youth are more likely to be exposed to family environments characterized by abuse, neglect, and to have poorer parent–child attachment quality than non-suicidal youth. This study analyzed data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) to examine the relationships between perceived levels of parental support, symptom severity, and mental health service use in a nationally representative sample of suicidal adolescents in the U.S. (n = 1804). Higher levels of parental support were associated with a lower likelihood of mental health service use, lower levels of depression, and lower likelihood of an actual suicide attempt. Additionally, the presence of a suicide attempt and higher levels of depression were associated with a higher likelihood of mental health service use. When mediation effects were tested, the presence of a suicide attempt partially mediated the relationship between parental support and mental health service use. Implications discussed include the protective nature of parental support the need for more family-based interventions for this population.     

Caregiver Factors Predicting Service Utilization Among Youth Participating in a School-based Mental Health Intervention

Large numbers of children and adolescents experience diagnosable psychiatric disturbances; however, the majority of those with need do not utilize mental health services. Characteristics of caregivers are important predictors of which youth will access and continue to use services over time. In recent years school-based mental health intervention programs have played a key role in identifying youth with mental health needs and linking them to treatment. In this study we sought to identify the caregiver demographic and contextual factors that predict days of service use among youth participating in a school-based mental health intervention program. Our sample included 85 youth ages 5–18 and their caregivers. We analyzed the data using bivariate and multivariate Poisson regressions with caregiver factors as the independent variables and days of service as the dependant variable. We found significant bivariate and multivariate associations for every caregiver demographic (sex, age, race) and contextual (education, employment, income, insurance, health, strain, and was it the caregivers idea to seek treatment) factor that was examined. In this study we identified the caregiver factors that are likely important in predicting youth service utilization even when steps have been taken to improve identification and access.     

Supporting the Need for an Integrated System of Care for Youth with Co-occurring Traumatic Stress and Substance Abuse Problems

Adolescents are at high risk for violence exposure and initiation of drug use. Co-occurring substance use and trauma exposure are associated with increased risk of mental health disorders, school underachievement, and involvement with multiple systems of care. Coordination and integration of systems of care are of utmost importance for these vulnerable youth. This study delineates the negative sequelae and increased service utilization patterns of adolescents with a history of trauma, substance abuse, and co-occurring trauma and substance abuse to support the need for integrated mental health and substance abuse services for youth. Data from two national sources, the National Child Traumatic Stress Network and Center for Substance Abuse Treatment demonstrate the increased clinical severity (measured by reports of emotional and behavioral problems), dysfunction, and service utilization patterns for youth with co-occurring trauma exposure and substance abuse. We conclude with recommendations for an integrated system of care that includes trauma-informed mental health treatment and substance abuse services aimed at reducing the morbidity and relapse probability of this high-risk group.     

Mental health service use by African American women: exploration of subpopulation differences

Studies focusing on mental health service use have consistently viewed African American women as a homogeneous population, and very few studies have examined subgroup differences. However, important differences exist both within and between groups in lifestyle, stressors, type and availability of support resources, societal interactions, and risk-taking behaviors. This study examined rates and patterns of mental health service use by African American lesbian women and a matched sample of heterosexual women. Results suggest both similarities and differences in factors associated with use of services. Despite evidence of substantial emotional distress, relatively few African American lesbian and heterosexual women reported current use of mental health services. These findings are consistent with past reports on African American heterosexual women but differ from other published reports on lesbians' use of therapy. Findings from this study, including clear differences between lesbians and heterosexual women in past use of therapy and preferences for mental health providers, have important implications for service provision.     

Health and Social Services for Male-to-Female Transgender Persons of Color in San Francisco

SUMMARY

This article presents findings from an investigation of health needs, service utilization, and perceived barriers to services among male-to-female (MtF) transgender persons of color in San Francisco. Focus groups (n = 48) and survey interviews (n = 332) were conducted with convenience samples recruited from the community. Participants reported a range of health and social services needed during the previous year, with African-Americans and Latinas showing particularly strong service needs. Rates of utilizing services were high for basic health care but lower for social services, substance abuse treatment, psychological counseling, and gender transition-related medical services. No significant ethnic group differences in health service utilization were found. Qualitative findings evinced the call for transgender-specific programs and advanced provider training on transgender issues such as hormone use, gender transition, HIV/ AIDS care and prevention, substance abuse, and mental health problems.     

Predictors of Recent Mental Health Service Use in a Medical Population: Implications for Integrated Care

This study investigated the relationship between physical and mental health and psychosocial variables and recent (within the last 12 months) mental health service use among 240 medical patients recruited from general and specialty outpatient clinics at an academic medical center. Results indicated 43.3% of the participants had recently received mental health services in the form of psychotropic medication (75%), psychotherapy (2%), or a combination of these treatments (20.2%). Among patients with moderate to severe symptoms of anxiety or depression, approximately two-thirds were receiving mental health treatment. Moreover, four variables (healthcare provider referral for mental health services, perceived need for mental health services, prior use of mental health services, and frequency of medical appointments) were significant unique predictors of recent mental health service use. This suggests collaborative/integrated medical care may increase needed mental health service use.     

National suicide prevention lifeline: enhancing mental health care for suicidal individuals and other people in crisis

Linking at-risk callers to ongoing mental health care is a key goal of crisis hotline interventions that has not often been addressed in evaluations of hotlines' effectiveness. We conducted telephone interviews with 376 suicidal and 278 nonsuicidal crisis callers to the National Suicide Prevention Lifeline (Lifeline) to assess rates of mental health care utilization following Lifeline calls and to assess attitudinal and structural barriers to service utilization. Postcall utilization rates were approximately 50% for suicidal and crisis callers who received mental health care referrals. Lack of health insurance and callers' perceptions about mental health problems emerged as significant barriers to accessing continued help.     

Evaluating Turkish university students’ preferences for mental health therapists: A conjoint analysis approach

Due to fast-paced cultural and societal changes in Turkey, Turkish students now accrue both eastern and western cultural motives, which place Turkish students under stress. However, Turkish students have a stigma toward seeking mental health services. The current study aimed to use conjoint analysis to examine Turkish students’ preferences for mental health therapist variables regarding seeking help for adjustment problems to life in college. Students from two universities in Turkey were recruited on a volunteer basis to participate in this study (N = 235). The results indicated that the training institution, age, professional background, geographical region and gender significantly influence students’ formation of preferences for mental health therapists. The training institution had the most predominant effect on preferences. Implications for promoting help-seeking and mental health service utilization in Turkey are discussed.     

A Paradigm for Studying the Accuracy of Self-Reports of Risk Behavior Relevant to AIDS: Empirical Perspectives on Stability, Recall Bias, and Transitory Influences

Despite the importance of the issue for AIDS-related research, there is a paucity of studies that have addressed the issue of the validity of self-reports of patterns of risk behavior over time. This article frames issues of measurement in the context of cognitive psychology and presents a research paradigm that investigators can use to explore issues of accuracy, bias, and stability in self-reports. The paradigm also permits the analysis of transitory influences on risk behavior, influences which have been minimized in current AIDS research. Preliminary data are presented that support the feasibility of the method and which are suggestive of important considerations in the development of valid measures in national surveys.     

Some effects of positive life events on community mental health

Measures of positive and negative events were derived from a life-event inventory to test the predictions of an equilibrium model and a positive mental health model of psychological well-being. These measures were related to indicators of individual and community well-being with data obtained through a household survey of 454 residents. Residents who reported more negative events also reported more psychological distress and less positive adjustment. Positive events were associated with reports of positive adjustment. An analysis of census tract scores on life events revealed that the relative absence of positive events in census tracts was associated with higher service utilization rates to the community mental health center serving those tracts. The number of negative events was unrelated to service rates for census tracts but was related to several demographic indicators of well-being.