Use of general medical care services by persons with mental disorders.

Data are presented on the medical diagnoses and the type of general medical services used by persons with mental disorder diagnoses. This study is based on the 1975 experience of registrants in four medical programs contained in three organizational settings. The data on services were retrieved from each program's automated date system. The percent of patients seen in general medical departments receiving a mental disorder diagnosis ranged from 4.8% to 13.6% among the four programs. Patients with mental disorder diagnoses visit general medical departments from 11/2 to two times as frequently as patients without such diagnoses. Persons with a diagnosed mental disorder are likely to receive care for conditions in more International Classification of Diseases categories than other patients, and are more likely to receive a diagnosis for ill-defined conditions, signs, and symptoms.

Diagnosed mental disorder in children and use of health services in four organized health care settings.

The authors present comparative data on the extent, nature, and impact of diagnosed mental disorder among children under 18 years of age seen during 1975 in four organized health care settings. Between 3.3% and 10.1% of the children seen were diagnosed as having a mental disorder in the study year, representing an annual prevalence of between 2.2% and 8.2% of the "covered" child populations. Transient situational disturbances, behavior disorders, and special symptoms were the most common diagnoses; the more severe disorders (organic brain disease, schizophrenia, and affective and other psychoses) accounted for less than 4% of all diagnosed mental disorder. Patients with diagnosed mental disorder used non-mental-health services (except those of pediatricians) appreciably more often than did patients without such a diagnosis.

Identification and care of problems associated with alcohol ingestion in pregnancy.

Fetal alcohol syndrome (FAS) and alcohol-related birth defects (ARBD) are fully preventable if alcohol use is separated from pregnancy. However, accomplishing this can be much harder than it might seem. This article describes some strategies for identification and treatment of women who drink during pregnancy.

Alcoholism treatment offset effects: an insurance perspective.

This study investigates whether alcoholism treatment costs are offset by reductions in other medical treatment costs by comparing people treated for alcoholism with a matched comparison group. The alcoholism treatment group is defined by diagnoses of alcohol dependence, abuse, or psychoses from health insurance claims field between January 1980 and June 1987. A comparison sample was matched on age, gender, and insurance coverage. In this primarily methodological study, expected costs for nonalcoholism treatments were calculated from standardized regressions. Offset effects were measured from the insurer's perspective through differences in expected total nonalcoholism treatment costs in the periods preceding and following alcoholism treatment. Members of the alcoholism treatment group were more likely than the comparison group to be hospitalized and to need other (nonalcoholism) medical treatment, thus incurring higher total costs. Offset effects emerged for patients with alcohol abuse and without mental psychosis comorbidities.

A discrete choice model of drug abuse treatment location.

OBJECTIVE: To identify short-term drug abuse treatment location risk factors for ten large, self-insured firms starting January 1, 1989 and ending December 31, 1991. DATA SOURCES/STUDY SETTING: Study population selected from a large database of health insurance claims for all treatment events starting January 1, 1989 and ending December 31, 1991. STUDY DESIGN: A nested binomial logit method is used to estimate firm-specific patterns of treatment location. The differences in treatment location patterns among firms are then decomposed into firm effects (holding explanatory variables constant among firms) and variable effects (holding firm-specific parameters constant). PRINCIPAL FINDINGS: Probability of inpatient drug treatment is directly related to the type of drug diagnosis. The most important factors are diagnoses of drug dependence (versus drug abuse) and/or a cocaine dependence. Firm-specific factors also make a substantive difference. Controlling for patient risk factors, firm-specific probabilities of inpatient treatment vary by as much as 87 percent. Controlling for practices of firms and their insurance carriers, differing patient risk profiles cause probabilities of inpatient treatment to vary by as much as 69 percent among firms. Use of the outpatient setting increased over the three-year period. CONCLUSIONS: There are two plausible explanations for the findings. First, people beginning treatment later in the three-year period had less severe conditions than earlier cases and therefore had less need of inpatient treatment. Second, drug abuse treatment experienced the same trend toward the increased use of outpatient care that characterized treatment for other illnesses in the 1980s and early 1990s.

Heeding the alcoholic beverage warning label during pregnancy: multiparae versus nulliparae.

OBJECTIVE: We compared the impact of the Federal Alcoholic Beverage Warning Label on multiparae (women with at least one previous live birth) and nulliparae (women with no previous live births). The label, implemented on November 18, 1989, urges women not to drink during pregnancy because of the risk of birth defects. If multiparae drank during prior pregnancies, delivering apparently normal babies, we hypothesized that the warning might be less salient for them. METHOD: We studied 17,456 inner city black gravidas seen between September 1986 and September 1993 at one antenatal clinic. Time series analysis (ARIMA) examined trends in monthly means of antenatal drinking scores (alcohol consumption adjusted for weeks' gestation, age, parity and periconceptional drinking). RESULTS: For nulliparae (n = 7,349), reported drinking began to show a significant decline in June 1990, 7 months after the implementation of the warning label (t = 2.00, p < .04). In contrast, multiparae (n = 10,107) showed no change in reported drinking (t = 1.23) postlabel. CONCLUSIONS: Given previous results that multiparae drink more and that heavier drinkers are ignoring the warning label, these data are very distressing and suggests the importance of targeting multiparae for intensive prevention efforts.

Mental health services research issues in the Veterans Administration.

In 1975 the Veterans Administration treated 351,000 veterans in psychiatric inpatient services and had 2.7 million psychiatric outpatient visits and 10% of all psychiatric beds in the United States. The VA has led the nation in a shift toward outpatient treatment of psychiatric disorders. The VA patient population differs from the rest of the country in that VA psychiatric patients have a higher incidence of psychoses and organic brain syndrome as well as being older, being predominantly male, and having a higher rate of chronic disorders. Mental health services research directed toward the VA medical care system falls into two major categories: utilization and patterns of care, and quality and effectiveness of care. Several possible avenues of research are offered in each of these two major areas.

Extent of depressive symptomatology among patients seeking care in a prepaid group practice.

A total of 1921 consecutive adult patients seen in the Departments of Internal Medicine and Obstetrics-Gynaecology at a prepaid group practice completed a self-administered depressive symptomatology questionnaire, the Centre for Epidemiologic Studies Depression Scale (CES-D). New health practitioners and physicians, who were not mental health specialists, blindly judged the presence or absence of depressive symptomatology. Twenty-one per cent of the patients suffered from depressive symptoms according to the CES-D, but only 15% of these were judged to be depressed by their physician or new health practitioner. The variables which predict the recognition of depressive symptomatology are discussed.

The persistence of depressive symptomatology among prepaid group practice enrollees: an exploratory study.

This exploratory study examines the persistence of depressive symptomatology as measured by the Center for Epidemiological Studies Depressive Scale (CES-D). Over as 12-month period, half of the group of 309 prepaid group practice enrollees reporting depressive symptoms at the beginning of the interval also had high scores on the CES-D at the end of the interval. Sociodemographic characteristics did not predict persistence of depression. Persistence of depression was positively associated with initially reporting cognitive and affective types of depressive symptoms, the presence of physical illness, the seeking of psychiatric treatment, and the receipt of psychotropic drug prescriptions.

Episodes of psychiatric utilization.

The continued growth of outpatient psychiatric care has been accompanied by a large number of research studies concerning the determinants of psychiatric utilization. One of the major limitations of these efforts has been the inability to go beyond distributional data on the use of services. This article describes a methodology for generating episodes of psychiatric care given a data set with a small amount of routinely collected data present in many medical information systems. Both demographic and medical characteristics are significantly associated with health services resource use as defined by the number of visits in an episode. A model predicting recurrent episodes of care is also described. The general utility of this approach and the substantive implications of the specific results are discussed.

The impact on utilization of a copayment increase for ambulatory psychiatric care.

The impact of a copayment increase on the utilization of psychiatric services in a prepaid group practice program is examined. Data are presented on utilization at the Columbia Medical Plan (Columbia, Maryland) two years before and two years after the copayment increase. There was a highly transient response to the increse in the copayment for psychiatric care. The year of the copayment increase was characterized by a small decline in the proportion of enrollees using psychiatric care, and a slight decrease in the utilization rate. These declines were short-lived, and utilization returned to previous levels one year after the copayment increase.

Episodes of psychiatric care and medical utilization.

This study examines the reduction in medical care utilization after mental health treatment, also known as the offset effect. With data from a computerized ambulatory care information system, an episode-of-care method is used to characterize the mental health care received by patients in a prepaid group practice. The characteristics of the psychiatric episodes, such as duration, type of therapy, and number of visits, are examined in relation to the degree of offset effects among psychiatric patients. The results indicate that offset effects are most pronounced for a variety of characteristics related to the psychiatric episode of care including brief, high-intensity therapy, treatment for transient rather than chronic mental illness, and individual rather than group therapies. Finally, this study replicates two major findings in the offset literature: the characteristic peaking of medical use before mental health care and the short-term nature of the offset effect.

Short term drug abuse treatment costs and utilization: a multi-employer analysis.

OBJECTIVES: This report investigates three aspects of drug abuse treatment costs, with special emphasis on systematic differences among employers: (1) predictors of drug abuse treatment costs; (2) differentials in drug abuse treatment costs across employers; and (3) differential impacts of patient and employer characteristics on drug abuse treatment costs. METHODS: The study used multiple regression analysis of behavioral cost functions. It decomposed cost differences into employer and variable effects using an algebraic method that accounted for differences in cost functions and in population characteristics. An insurance claims database was used from 10 large self-insured employers for a 3-year period starting January 1989. RESULTS: Marginal inpatient costs generally exceeded average costs, leading to slightly increasing costs per day as length of stay increased. Marginal outpatient costs were generally about the same as average costs, implying that outpatient drug treatment maintained constant unit costs as utilization increased. Decomposition of cost differences among employers suggested that observed differences among employers and/or their carriers (who administer the benefits for the self-insured employers) and providers appeared to be at least as important as differences among the characteristics or the utilization of the people that they cover. CONCLUSIONS: National health policies aimed at reducing costs are likely to have differing impacts on different employers. Employers with high costs relative to the characteristics of their covered population may be able to achieve significant cost savings. Employers serving populations with greater risk factors may find it difficult to cut costs further.

An analysis of short-term alcoholism treatment cost functions.

A number of alcohol treatment studies have documented variations in the average cost of treating alcoholics. However, these studies have provided little explanation for these variations. In this study, three major issues in the measurement of alcoholism treatment costs are investigated: 1) choice of treatment location, i.e., inpatient versus outpatient; 2) interaction of treatment locations in the estimation of costs; 3) impact of type of alcohol problem and comorbidities on treatment costs. The study includes an integrated framework that jointly estimates treatment location and treatment costs conditional on treatment location, concentrating on short-term alcoholism treatment and using insurance claims data to specify a 6-month period beginning with each individual's first treatment for alcoholism. The different treatment types subsumed in the categories alcohol abuse and alcohol dependence are also addressed. Results indicate that comorbidities are crucial in determining treatment location. Once treatment location is determined, however, their effects on treatment costs, while measurable, are statistically insignificant. Partial treatment effects, conditional on treatment location, differ substantially from full treatment effects, which are determined jointly with treatment location.

A discrete choice model of alcoholism treatment location.

In this study, a discrete choice model of alcoholism treatment location, with special emphasis on the roles of comorbidities is considered. Three specific questions are addressed: 1) what demographic and health factors have significant impacts on treatment location for both short- and long-term alcoholism and nonalcoholism treatments?; 2) how does the impact of alcohol dependence differ from the impact of alcohol abuse, on probabilities of short-term or long-term inpatient treatment?; and 3) what are the impacts of health comorbidities on probabilities of inpatient treatment in the short or long term? A binomial logit model is estimated for short- and long-term alcoholism treatment, as well as for short- and long-term nonalcoholism treatment (which occurs at the same time). The results indicate the importance of comorbidities in predicting treatment location. They also indicate a trend during the 1980s toward increased use of outpatient rather than inpatient treatment.

Has awareness of the alcohol warning label reached its upper limit?

Has awareness of the alcoholic beverage warning label reached its maximum? This study tracks changes in the level of awareness among a sample of 7334 inner-city African-American gravidas seeking prenatal care between May 1989 and June 1993. Previously, we found that a significant increase in awareness of the warning label occurred in March 1990. In the current analysis over a 50-month period, the level of awareness continued to increase through December 1992 and then leveled off, suggesting a negatively accelerated growth function. The logistic function fitted to the awareness curve predicts that the upper limit of awareness in this population has been reached (the predicted upper limit being 81.5%). In addition a logit regression analysis showed that women who did not know about the warning label were more likely to be over 29 years of age. Heavier drinkers were 1.25 times more likely to be aware of the label. Among those drinkers who were not aware of the label, 30% drank at both conception and antenally, thus putting their fetus at high risk for alcohol-related birth defects.

A time series analysis of the impact of the alcohol warning label on antenatal drinking.

In a sample of over 12,000 African-American gravidas, we tested the hypothesis that the Federal Beverage Labeling Act of 1988 has decreased antenatal drinking. Results of time series analysis indicated a 7-month lag in the impact of the alcohol warning label. Controlling for population changes, antenatal drinking began to fall as of June 1990. However, this decrease was small in size and did not impact on the heaviest drinkers. Seasonal trends in drinking were also detected, with peaks around the end of the year and the summer.

A longitudinal study of offset in the use of nonpsychiatric services following specialized mental health care.

This study examines the use of nonpsychiatric services by mentally ill persons following the receipt of specialized mental health care, frequently referred to as the "offset effect." A total of 9,761 persons enrolled during 1975 in the Columbia Medical Plan, a prepaid group practice in Columbia, Maryland, were studied over a 5-year period. Enrollees were classified into three groups: Treated--mental disorder diagnosis in 1975 and specialized mental health care in 1975; Untreated--mental disorder diagnosis in 1975 but no specialized mental health care in that year; and Comparison--neither mental disorder diagnosis nor specialized mental health care in 1975. The nonpsychiatric utilization for these groups was compared for 1973-1977. Specialized mental health care appears to have a short-term effect on nonpsychiatric utilization by attenuating the peak in use. Mentally ill persons without specialized mental health care in 1975 also reduced their use of nonpsychiatric services in 1976-1977. The utilization changes were more likely to occur in primary care departments, rather than nonpsychiatric specialty care departments. A diagnosis of mental disorder in either 1973 or 1974 was associated with a larger offset effect.

The alcohol beverage warning label: when did knowledge increase?

This article presents data on the awareness of the alcohol beverage warning label among a sample of 5,169 inner city African-American gravidas seeking prenatal care. While the label law was implemented in November 1989, a significant increase in knowledge of the label did not occur until March 1990. Women who predominantly consumed wine coolers and beer, and those under age 30 were more likely to know about the label than their counterparts.