A mental health capitation program: I. Patient outcomes.

OBJECTIVE: The Monroe-Livingston demonstration project's capitation payment system (CPS) was evaluated to determine whether capitated funding of mental health care, compared with fee-for-service funding, could reduce hospitalization rates and improve functioning and symptoms for severely and persistently mentally ill adults without increasing the total cost of care. METHODS: The experiment was a communitywide prerandomized clinical trial involving 422 patients. Patients who were randomized into the experimental group were eligible for enrollment in a capitated funding program administered by one of five community mental health centers. Those randomized into the control group received standard fee-based services. Follow-up interviews with patients one and two years after enrollment in the study assessed changes in symptoms and functioning. Data files of the membership corporation that coordinated community mental health services for the CPS provided measures of study patients' use of inpatient mental health services. RESULTS: During the two-year follow-up period, patients in the experimental group had significantly fewer hospital inpatient days than patients in the control group, but the two groups had no significant differences in functioning or level of symptoms. CONCLUSIONS: The CPS successfully maintained severely ill patients in the community but did not improve their functioning or level of symptoms.

A mental health capitation program: II. Cost-benefit analysis.

OBJECTIVE: Total monetized and nonmonetized costs and benefits to society of the Monroe-Livingston demonstration project's capitated payment system (CPS) were analyzed. METHODS: Total costs and benefits of care for individuals who were prerandomized to an experimental group (of whom about 57 percent were enrolled in the CPS) were compared with those for a control group who received traditional fee-for-service care. Separate two-year results are presented for continuous patients, who were enrolled in a comprehensive CPS plan (N = 201) and for intermittent patients, who were enrolled in a partial plan (N = 155). RESULTS: All groups showed improvements on many psychosocial measures over the two years. Continuous patients in the experimental group experienced less hospitalization, more case management and transportation services, and higher levels of victimization and were more likely to live in unsupervised settings than continuous patients in the control group. Total annual per patient costs for care of continuous patients ranged from $74,000 to more than $100,000, largely reflecting differences in rates of hospitalization. Experimental subjects in the partial capitation condition differed from the control group in this plan on fewer measures; both groups reported high levels of case management and social support services and relatively lower levels of supervised housing. CONCLUSIONS: The CPS resulted in major improvements in the community's services for persons with serious mental illness and reduced the proportion of care provided in the state hospital.

Methodology for evaluating the Monroe-Livingston capitation system.

This paper presents the methodology for evaluating the Monroe-Livingston demonstration project's capitation payment system (CPS), based in Rochester, New York, for chronic mentally ill patients. To allow for both patient and provider choice within the experimental design, 1,587 CPS-eligible patients were randomly assigned at the start of the study to control or experimental conditions, with the intent of capturing in the experimental group a significant number of patients who would later be enrolled in the CPS. Protocols, which included measures of symptomatology, functioning, and resource utilization, were completed at baseline for 422 of the 605 patients contacted for inclusion in the study. The baseline control group included 143 patients; the experimental group included 279 patients, 153 of whom were eventually enrolled in the CPS.

Suicide in psychiatric and non-psychiatric populations.

An analysis of all 776 suicides reported in Monroe County, New York, from 1966 through 1975 showed that psychiatric patients differ in systematic ways from other individuals who commit suicide. Forty-three percent of the total suicides were committed by patients with recorded contacts in the Monroe County Psychiatric Case Register. While suicide rates by age and sex for the overall population were similar to those reported previously, rates for the subgroup of psychiatric patients yielded little variation by age or sex.

The epidemiology of treatment for chronic and nonchronic mental disorders.

To estimate the annual treated incidence and prevalence of chronic and nonchronic mental disorders, data from the Monroe County Psychiatric Register were analyzed. Patients were classified as either chronic or nonchronic based upon their utilization of inpatient psychiatric treatment. A chronic illness was defined as one requiring at least three psychiatric hospitalizations or at least 365 inpatient days during a 5-year follow-up period. Based upon this definition, the annual treated incidence of chronic mental disorders did not change significantly between 1964-65 (.47/1000) and 1969-70 (.41/1000), unlike the annual treated incidence of nonchronic disorders, which rose by 37 per cent (p less than .001). The annual treated prevalence of chronic mental disorders also remained unchanged at approximately .6 per cent between 1965 and 1970, but the treated prevalence of nonchronic mental disorders rose by 43 per cent from 1.4 per cent in 1965 to 1.9 per cent in 1970 (p less than .01). These increases in treatment for nonchronic disorders coincided with the development of community mental health centers. The rates of chronicity and peak ages of treatment varied considerably across diagnostic groups. Approximately one fifth of new cases of organic brain disorders, schizophrenia, and alcohol disorders became chronic according to our definition during the first 5 years after illness onset, compared to only 9 to 11 per cent of cases of major affective disorders and less than 2 per cent of all other disorders.(ABSTRACT TRUNCATED AT 250 WORDS)

Behavioral disorders in multiple sclerosis, temporal lobe epilepsy, and amyotrophic lateral sclerosis. An epidemiologic study.

Certain CNS diseases can produce specific behavioral abnormalities. We used a computer search technique to identify all inpatients at Strong Memorial Hospital, Rochester, NY, who had received diagnoses of multiple sclerosis (MS), temporal lobe epilepsy (TLE), and amyotrophic lateral sclerosis (ALS) between 1965 and 1978. We found 368 patients with MS, 402 patients with TLE, and 124 patients with ALS. These groups were matched against the Monroe County (New York) Psychiatric Register to determine patterns of behavioral pathology. Prevalence rates for psychiatric contact were not significantly different between MS and TLE (19.3% v 22.9%), but both were higher than the prevalence rate for ALS (4.8%). When behavioral patterns were assessed, patients with MS demonstrated a significantly higher rate of depressed affective disorders (61.97% of register matches) than patients with the other two diseases. Multiple sclerosis may present a neurologic model for mood disturbance.

Mental health problems of children: analysis of a cumulative psychiatric case register.

The advent of community mental health centers has brought a marked increase in treatment of mental health problems of children, especially for minorities. The number of children receiving care and the prevalence and the utilization rates by age, sex, and race from 1960 to 1977 in a large metropolitan county in upstate New York have been described previously. For the same time and community, the episodes of care by diagnostic grouping, type and length of treatment, and health status at the end of an episode have now been examined. An increase in treatment occurred in two areas: situational disorders and behavioral disorders. The number of treatments for psychotic, neurotic, and personality disorders remained stable. Affective and psychotic disorders emerged as qualitatively unique problems which often required multiple treatments and predicted high adult utilization. The average length of treatment for all episodes was 110 days. One third of the treatment episodes were associated with an improved health status. Most contacts were for first episodes, but a few patients had an extraordinarily large number of treatment episodes. A comparison with mental health problems seen in pediatric practice is presented.

Epidemiologic considerations in electroconvulsive therapy.

Data from the Monroe County (New York) Psychiatric Case Register were grouped for 1961 through 1965, 1966 through 1970, and 1971 through 1975 for comparisons of incidence, prevalence, mortality, and length of stay associated with electroconvulsive therapy (ECT). While incidence of first ECT series declined substantially from 1961 through 1965 to 1971 through 1975 in most age-sex groups, significant declines in prevalence of admissions involving ECT occurred only among young female patients. Both prevalence and incidence analyses showed increasing specificity over time of ECT use in cases of depression. Demographic characteristics associated with ECT were accounted for by diagnostic correlates. Mortality effects associated with use of ECT were not pronounced, though a lower rate of accidental and circulatory deaths in the ECT group was noted. Lengths of hospital stay for patients receiving ECT were generally longer than for other depression hospitalizations, both for first ECT and later ECT series.

The increasing number of children using psychiatric services: analysis of a cumulative psychiatric case register.

Psychosocial problems of children have received increasing attention in the pediatric literature, but it remains unclear to what extent psychiatric services are available and used for the treatment of these problems. This paper examines the utilization of psychiatric services by children over an 18-year period in Monroe County, NY, where a psychiatric case register monitors utilization since 1960. Reporting to the register is estimated at more than 90% of utilization for the child population. By 1977, the last year for which reasonably complete data are available, enough information had accumulated to study the lifetime utilization of all children up to 17 years of age. During the last three years of the study period, the lifetime prevalence of illness treated in psychiatric facilities including private psychiatrists' offices was 3% for children aged 5 to 9 years, 5.5% for children aged 10 to 14 years, and 7.3% for those aged 15 to 17 years. The incidence of newly recognized and treated illness was approximately .7% per year in the age range 5 to 14 years and 1.0% for those aged 15 to 17. Community mental health centers brought a marked increase in treated incidence especially for the nonwhite population. Utilization rose during the first 15 years of the study period and reached a plateau by the mid-1970s. Two interpretations of this stabilization of utilization are offered. The first one suggests that needs and utilization are still increasing, but that this rise is masked in the data by a drop in reporting providers. The second interpretation suggests that supply and demand for services have become balanced since the establishment of four community mental health centers.

Epidemiology of anorexia nervosa in Monroe County, New York: 1960-1976.

The Monroe County Psychiatric Case Register and hospital records were used to investigate the incidence of anorexia nervosa in Monroe County, New York, during the periods 1960-1969 and 1979-1976 to determine whether the number of newly diagnosed cases has increased over time. The results support the general clinical impression of a recent increase in the incidence of anorexia nervosa. This pattern of overall change was accounted for by the sharp increase in the number of females with the disorder, particularly those aged 15-24. The data also suggest that the disorder occurs more often in the higher socioeconomic levels.

Migrant farm workers: social conditions, adaptive belief systems, and psychiatric care.

Two migrant farm labor camps were observed during two summer harvesting seasons. A part of the observations consisted of interviews with 104 farm laborers, with 16 of them being interviewed intensively. Migrant farm workers were exploited by the crew boss and the farm owner, and they in turn exploited each other. Consequently, many workers left farm work. Those who remained in the camps adapted their attitudes and their views to the conditions. Though they had a begrudging respect for the crew boss, they showed an overriding concern with exploitation. They conveyed a numbness about life, themselves, and their place in society; this numbness was combined with self criticism and an attempt to maintain some self-respect. They expressed distrust for and suspicion of others, and though they could not articulate it very well, they felt great fear and anxiety. In order to diagnose and treat disorder in migrant farm workers, psychiatrists must understand the exploitive social setting of migrant farm work and the adaptations of workers to that setting.

Patterns of death among suicide attempters, a psychiatric population and a general population.

This epidemeological study examines patterns of mortality for a population of suicide attempters, a psychiatric population without suicide attempts, and a general population without psychiatric histories in order to clarify earlier reports of differential risks of death associated with these groups. Mortality patterns were investigated over an 11-year period in terms of demographic characteristics and rates of death by various causes. Suicidal deaths were given special attention to identify variables that may have predictive validity for suicide. The results indicate that the suicide attempter group represents a distinctive demographic and mortality entity from either the psychiatric or general populations, and accounts for much of the increased risk of death previously attributed to the psychiatric population. Further, premature deaths due to suicide are strongly associated with the suicide attempter group. The psychiatric and general populations differ in relatively insignificant ways. These results suggest that a profitable approach to the prevention of suicide would be to focus on individuals who were at high risk within the suicide attempter population. Longer-term follow-up of these individuals is necessary if deaths due to suicide are to be prevented. Difficulties associated with implementation of preventive follow-up programs are also discussed.

The impact of community mental health centers on the utilization of services.

The impact of community mental health centers on the utilization of psychiatric services in Monroe County, New York, was evaluated by means of data from the Monroe County Psychiatric Case Register. The catchment areas that received centers served as their own controls. In addition, yearly utilization rates were compared for areas that obtained centers with those remaining centerless. Utilization rates increased markedly in catchment areas with centers, while the percentage of patients seen at the Rochester Psychiatric Center decreased from all catchment areas. Community mental health centers increased the utilization rates of the poor, children, and young adults, while the treatment needs of patient subgroups such as alcoholics, drug addicts, and the elderly were last to be addressed. The data do not evaluate issues such as the character, quality, and effectiveness of care.

Suicide by persons with and without psychiatric contacts.

A two-year sample of 179 consecutive suicides in Monroe County, New York, was divided according to the presence or absence of previous psychiatric contacts based on a country-wide psychiatric case register (PCR). After a brief description of the total suicide group, the 45% of suicides with PCR contacts are compared to the suicides without such contacts and to the total PCR population. Findings suggest that there are some important differences between psychiatric patients at high risk for suicide compared to other groups. The PCR suicides were almost equally male or female, had a median age of 42 years, had high proportions of persons divorced or widowed, and unemployed or retired. Persons diagnosed as alcohol abusers, or as having affective psychosis, depressive neurosis, or schizophrenia were especially at risk.

Risks of mortality of suicide attempters compared with psychiatric and general populations.

This study compares mortality risk among suicide attempters, psychiatric patients, and members of the general population using demographic data from the Monroe County (New York) Psychiatric Case Register for 1960 to 1970. During this 11-year period there were 172 deaths reported for the suicide attempt group, 6, 108 for the Psychiatric Register population, and 58,542 for the general population. The relative risk of death from all causes of the suicide attempt group was nearly twice that of the general population and slightly higher than that of the psychiatric group. High risks of mortality were differentially associated with several demographic and treatment variables. Implications for predictive criteria and interventive strategies are discussed.