Depression is Associated with Increased Risk for Metabolic Syndrome in Latinos with Type 2 Diabetes.

OBJECTIVE: Latino adults are 66% more likely to have diabetes relative to non-Latino white adults. Prior research identifies depression as a significant risk factor for metabolic syndrome (MetS), but research examining this among Latinos is lacking. This study sought to examine the links between depression and MetS and clinically significant elevations in cardiovascular disease risk markers of MetS in a sample of community-dwelling older Latinos with type 2 diabetes. METHODS: Participants were 332 community-dwelling older (≥60 years) Latinos with type 2 diabetes who completed the nine-item Patient Health Questionnaire and received a health checkup assessing body mass index (BMI), triglyceride and high-density lipoprotein (HDL) cholesterol levels, and blood pressure. Logistic regression analysis compared MetS rates of those meeting criteria for depression with those who did not. Secondary analyses examined the associations between depression and individual MetS components. All analyses controlled for demographic (e.g., income, age) and other potential MetS risk factors (e.g., smoking status, physical activity, alcohol level consumption). RESULTS: Depression was significantly associated with an increased risk of MetS (OR: 5.79; 95% CI: 1.32-25.42) and clinically significant elevations in triglycerides (OR: 2.71; 95% CI: 1.15-6.42) and reduced (HDL) cholesterol (OR: 2.46; 95% CI: 1.11-5.45). A significant association was not observed between depression and either BMI or hypertension. CONCLUSION: Depression is significantly linked to MetS, and most notably dyslipidemia, in older Latinos with diabetes. Causation, however, cannot be inferred from these analyses given the cross-sectional nature of the study. Future research should prospectively examine the directionality of this effect.

Predisposing, enabling, and need factors associated with high service use in a public mental health system.

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.

Access to public mental health services among older adults with severe mental illness.

OBJECTIVE: Limited data are available on how older adults access public mental health systems. This study examines how uninsured or publicly insured older adults with severe mental illness in San Diego County initially accessed the public mental health system, as well as their subsequent use of public mental health services, as compared to younger adults. METHODS: Data from San Diego County, 2002-2006, were used to examine how older adults initially accessed the public mental health system, and their utilization over the subsequent 90 days. Multivariate regression models were used to control for demographic and clinical characteristics. RESULTS: Older adults (age 60 +) were more likely to access the public mental health system through the Psychiatric Emergency Response Team (PERT), a combined law-enforcement and psychiatric service that responds to psychiatric related 911 calls. Older adults were also less likely to receive follow-up care. This lower rate of follow-up was due to both the initial site of service--and an associated lower rate of follow-up among PERT clients--as well as a lower rate of follow-up among older adult clients initiating services in other sectors. CONCLUSIONS: This paper suggests two areas for intervention that would improve access to care for older adults: improving linkages and referrals between PERT and outpatient providers; and additional efforts to retain older adults at outpatient programs.

Public-academic partnerships: improving care for older persons with schizophrenia through an academic-community partnership.

Translating evidence-based mental health interventions designed in research settings into community practice is a priority for multiple stakeholders. Partnerships between academic and public institutions can facilitate this translation. To improve care for middle-aged and older adults with schizophrenia, the authors developed a collaboration between a university research center and a public mental health service system using principles from community-based participatory research and cultural exchange theory. They describe the process that has led to a number of mutually beneficial products. Despite the challenges involved, building and maintaining academic-public collaborations will be essential for improving mental health care for persons with schizophrenia.

Unmet needs for mental health services for latino older adults: perspectives from consumers, family members, advocates, and service providers.

This study qualitatively assessed the need for mental health services among Latino older adults in San Diego, California. The primary mental health issue was depression. Primary organizational barriers to accessing services were language and cultural barriers secondary to a lack of translators, dearth of information on available services, and scarcity of providers representative of the Latino community. Other challenges included a lack of transportation and housing, and the need for socialization and social support. Latino older adults experienced their unmet needs in ways associated with their cultural background and minority status. Age- and culturally-appropriate services are needed to overcome these barriers.

A longitudinal study of the use of mental health services by persons with serious mental illness: do Spanish-speaking Latinos differ from English-speaking Latinos and Caucasians?

OBJECTIVE: 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. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.

Anxiety disorders in a public mental health system: clinical characteristics and service use patterns.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. LIMITATION: Data were taken from an administrative database. CONCLUSIONS: Data indicate that anxiety disorders are not uncommon in public mental health settings and are associated with higher utilization of outpatient mental health services.

Initiation and use of public mental health services by persons with severe mental illness and limited english proficiency.

OBJECTIVE: Few studies have examined the effect of limited English proficiency on use of mental health services by persons with mental illness from ethnic minority groups who are uninsured or publicly insured. This study examined how indigent or publicly insured Latino and Asian adults with limited English proficiency initially accessed the public mental health system and how their use of services changed over time compared with English-proficient peers. METHODS: Data from San Diego County for fiscal years 2000-2005 were used to examine point of first contact and use of inpatient, emergency, and outpatient services in the 18 subsequent months among 9,243 clients with a psychiatric diagnosis of schizophrenia, bipolar disorder, or major depression. Multivariate regression models were used to compute standardized estimates of utilization. RESULTS: Latino and Asian clients with limited English proficiency were significantly less likely to first access the system through emergency services and more likely to access the system through outpatient services (p<.001 for each comparison). In two outpatient programs that were focused on delivering services to clients with limited English proficiency, clients had a higher intensity of outpatient service use than clients in clinics that did not have such a focus (p<.05 for each). CONCLUSIONS: The initial pattern of service use was favorable for both groups. However, over time this pattern persisted for Asian clients with limited English proficiency but not for Latino clients with limited English proficiency. Findings suggest that ethnically focused programs may be an effective approach to engaging populations that are underrepresented in the mental health system.

Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system.

OBJECTIVE: 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. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.

Tri-ethnic variations of co-morbid substance and alcohol use disorders in schizophrenia.

OBJECTIVES: This study examined the differential prevalence of substance and alcohol use disorders among European Americans, African Americans, and Latinos with schizophrenia (n = 6424) who received public mental health services in San Diego County during fiscal year 2002-2003. METHODS: Data were obtained from the public mental health database used by the San Diego County Mental Health System. Chi-Square analyses and stepwise logistic regression analyses were used to examine differences regarding the prevalence of substance and alcohol use among clients with schizophrenia and schizoaffective disorder, and to analyze the sociodemographic variables associated with this co-morbidity. RESULTS: Significant differences in the prevalence of diagnosed co-morbidity were found across the ethnic groups. Rates of co-morbid diagnosis among African Americans (25%) were significantly higher than those among European Americans (22%) and Latinos (19%). Logistic regression results revealed ethnicity was a significant predictor of co-morbid substance and alcohol use, as was being homeless and male. Among Latinos, language preference was also a significant predictor. Latinos who denoted English as their primary language were 1.7 times more likely to be diagnosed with co-morbid substance or alcohol use disorders than Latinos who denoted Spanish. CONCLUSIONS: Among people with schizophrenia, there were significant differences in prevalence rates and predictors of diagnosed co-morbid substance and alcohol use disorders. Future research is needed to examine the relationship among language preference, level of acculturation, and subsequent diagnosing barriers for Latinos. Among African Americans, the reasons behind increased co-morbidity rates need to be examined, and homelessness should be carefully addressed among all three ethnic groups.

A randomized trial of short-term acute residential treatment for veterans.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Cost-sharing requirements and access to mental health care among medicare enrollees with schizophrenia.

OBJECTIVE: This study explored the association between Medicare cost-sharing requirements and the probability of use of various mental health outpatient services among Medicare enrollees with schizophrenia. METHODS: Multivariate logistic regression was used to estimate the probability of use of each of seven types of services over six months. Patients were recruited from public and private mental health treatment provider organizations in six states. The analyses included 1,088 Medicare enrollees, of whom approximately 55 percent were also enrolled in Medicaid. RESULTS: Medicare-only patients (with greater cost-sharing) were 25 to 45 percent less likely to have used rehabilitation services, individual therapy with nonpsychiatrist mental health providers, and case management. No association was found between Medicaid enrollment and probability of service use for medical clinic visits, group therapy, individual contact with a psychiatrist, or receipt of second-generation antipsychotics. CONCLUSIONS: Among Medicare enrollees with schizophrenia, gaps in Medicare coverage may be more problematic for rehabilitation, case management, and contact with nonpsychiatrist providers. Local public and private subsidies for mental health treatment may compensate for some of the gaps in coverage. However, such subsidies are not universally or uniformly provided.

Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia.

OBJECTIVE: The authors' goal was to evaluate the relationship between adherence to treatment with antipsychotic medication and health expenditures. A secondary objective was to identify risk factors predictive of nonadherence. METHOD: Data included Medicaid eligibility and claims data from 1998 to 2000 for San Diego County, Calif. Pharmacy records were used to assess adherence to treatment with antipsychotic medication according to the cumulative possession ratio (the number of days medications were available for consumption divided by the number of days subjects were eligible for Medi-Cal). Regression models were used to examine risk factors, hospitalizations, and costs associated with nonadherence, partial adherence, adherence, and excess fills of antipsychotic medication. RESULTS: Forty-one percent of Medicaid beneficiaries with schizophrenia were found to be adherent to treatment with their antipsychotic medications: 24% were nonadherent, 16% were partially adherent, and 19% were excess fillers. Rates of psychiatric hospitalization were lower for those who were adherent (14%) than for those who were nonadherent (35%), partially adherent (24%), or had excess fills (25%). Rates of medical hospitalization were lower for those who were adherent (7%) than for those who were nonadherent (13%) or had excess fills (12%). Those who were adherent had significantly lower hospital costs than the other groups; pharmacy costs were higher among those who were adherent than among those who were nonadherent or partially adherent and were highest for excess fillers. Total costs for excess fillers (14,044 US dollars) were substantially higher than total costs for any other group. CONCLUSIONS: Despite the widespread use of atypical antipsychotic medications, alarmingly high rates of both underuse and excessive filling of antipsychotic prescriptions were found in Medicaid beneficiaries with schizophrenia. The high rates of antipsychotic nonadherence and associated negative consequences suggest interventions on multiple levels.

Ethnic disparities in use of public mental health case management services among patients with schizophrenia.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Gender differences in characteristics and service use of public mental health patients with schizophrenia.

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.

Assisted living and use of health services among medicaid beneficiaries with schizophrenia.

BACKGROUND: 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. AIMS OF THE STUDY: 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. METHODS: 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. RESULTS: 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. DISCUSSION: 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. IMPLICATIONS FOR HEALTH POLICIES: 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. IMPLICATIONS FOR FURTHER RESEARCH: Research studies should be designed to evaluate characteristics of assisted living facilities that lead to improved function and outcomes among residents.

Change in mental health service use after offering youth-specific versus adult programs to transition-age youths.

OBJECTIVES: This study examined changes in service use associated with providing age-specific services for youths in their transitional years, ages 18­24. METHODS: A quasi-experimental, difference-in-difference design with propensity score weighting was used to compare mental health service utilization (use of outpatient, inpatient, emergency, and justice system services) among 931 youths enrolled in outpatient programs specifically for transition-age youths and 1,574 youths enrolled in standard adult outpatient programs in San Diego County, California, from July 2004 through December 2009. RESULTS: Among youths enrolled in outpatient programs geared toward youths of transitional age, the mean number of annual outpatient mental health visits increased by 12.2 (p<.001) compared with youths enrolled in standard adult outpatient programs. CONCLUSIONS: Compared with traditional adult outpatient mental health programs, age-specific programs were associated with an increased use of outpatient mental health services. Future research is needed to assess the effectiveness of age-specific programs for transition-age youths and how use of these programs relates to improved clinical, educational, and vocational outcomes over time.

Assessing needs for mental health and other services among transition-age youths, parents, and providers.

OBJECTIVES: This qualitative study assessed the needs for mental health and other services among transition-age youths who were receiving services in youth-specific programs. METHODS: Thirteen focus groups were conducted between June 2008 and January 2009. The purposefully sampled participants included transition-age youths age 18 to 24 who were receiving services in youth-specific programs (N=75, eight groups), parents of transition-age youths (N=14, two groups), and providers in the youth-specific programs (N=14, three groups). The qualitative analysis used an inductive approach in which investigators focused on generating themes and identifying relationships between themes. Through a process of repeated comparisons, the categories were further condensed into broad themes illustrating service needs. RESULTS: Youths expressed needs for improved scheduling of services, stronger patient-provider relationships, and group therapies that address past experiences of violence, loss, and sexual abuse and that provide skills for developing and nurturing healthy relationships. Parents and providers expressed needs for increased community-based and peer-led services. Youths, parents, and providers all expressed needs for more housing options and for mentors with similar life experiences who could serve as role models, information brokers, and sources of social support for youths who were pursuing education and employment goals. CONCLUSIONS: Findings from the focus groups suggest that there is room for improvement in the provision of services that are relevant to the current needs and life experiences of transition-age youths. Even within age-specific programs, improvements in services are needed to foster transitions to independence.

Adherence to antipsychotics among Latinos and Asians with schizophrenia and limited English proficiency.

OBJECTIVES: The authors examined data for 7,784 Latino, Asian, and non-Latino white Medi-Cal beneficiaries with schizophrenia to determine the relationship between patients' preferred language for mental health services--English, Spanish, or an Asian language--and their adherence to treatment with antipsychotic medications. METHODS: Data reflected 31,560 person-years from 1999 to 2004. Pharmacy records were analyzed to assess medication adherence by use of the medication possession ratio (MPR). Clients were defined as nonadherent (MPR<.5), partially adherent (MPR=.5-<.8), or adherent (MPR=.8-1.1) or as an excess filler of prescriptions (MPR<1.1). Regression models were used to examine adherence, hospitalization, and costs by race-ethnicity and language status. RESULTS: Latinos with limited English proficiency were more likely than English-proficient Latinos to be medication adherent (41% versus 36%; p<.001) and less likely to be excess fillers (15% versus 20%; p<.001). Asians with limited English proficiency were less likely than English-proficient Asians to be adherent (40% versus 45%; p=.034), more likely to be nonadherent (29% versus 22%; p<.001), and less likely to be excess fillers (13% versus 17%; p=.004). When analyses controlled for adherence and comorbidities, clients with limited English proficiency had lower rates of hospitalization and lower health care costs than English-proficient and white clients. CONCLUSIONS: Adherence to antipsychotic medications varied by English proficiency among and within ethnic groups. Policies supporting the training of bilingual and multicultural providers from ethnic minority groups and interventions that capitalize on patients' existing social support networks may improve adherence to treatment in linguistically diverse populations.

Establishing an implementation network: lessons learned from community-based participatory research.

BACKGROUND: Implementation of evidence-based mental health assessment and intervention in community public health practice is a high priority for multiple stakeholders. Academic-community partnerships can assist in the implementation of efficacious treatments in community settings; yet, little is known about the processes by which these collaborations are developed. In this paper, we discuss our application of community-based participatory research (CBPR) approach to implementation, and we present six lessons we have learned from the establishment of an academic-community partnership. METHODS: With older adults with psychosis as a focus, we have developed a partnership between a university research center and a public mental health service system based on CBPR. The long-term goal of the partnership is to collaboratively establish an evidence-based implementation network that is sustainable within the public mental healthcare system. RESULTS: In building a sustainable partnership, we found that the following lessons were instrumental: changing attitudes; sharing staff; expecting obstacles and formalizing solutions; monitoring and evaluating; adapting and adjusting; and taking advantage of emerging opportunities. Some of these lessons were previously known principles that were modified as the result of the CBPR process, while some lessons derived directly from the interactive process of forming the partnership. CONCLUSION: The process of forming of academic-public partnerships is challenging and time consuming, yet crucial for the development and implementation of state-of-the-art approaches to assessment and interventions to improve the functioning and quality of life for persons with serious mental illnesses. These partnerships provide necessary organizational support to facilitate the implementation of clinical research findings in community practice benefiting consumers, researchers, and providers.