Mental Health Service Use in Schools and Non-School-Based Outpatient Settings: Comparing Predictors of Service Use.

Researchers have consistently documented a gap between the large number of US youth meeting criteria for a mental health disorder with significant associated impairment, and the comparatively few youth receiving services. School-based mental health care may address the need-services gap by offering services more equitably to youth in need, irrespective of family economic resources, availability of transportation, and other factors that can impede access to community clinics. However, diagnoses alone do not fully capture the severity of an individual's mental health status and need for services. Studying service use only in relation to diagnoses may restrict our understanding of the degree to which service use is reflective of service need, and inhibit our ability to compare school and non-school-based outpatient settings on their responsiveness to service need. The present study evaluated predictors of mental health service use in school- and community-based settings for youth who had had an active case in one of two public sectors of care, comparing empirically-derived dimensional measurements of youth mental health service need and impairment ratings against non-need variables (e.g., ethnicity, income). Three dimensions of youth mental health service need were identified. Mental health service need and non-need variables each played a significant predictive role. Parent-rated impairment was the strongest need-based predictor of service use across settings. The impact of non-need variables varied by service setting, with parental income having a particularly noticeable effect on school-based services. Across time, preceding service use and impairment each significantly predicted future service use.

Reconsidering culturally competent approaches to American Indian healing and well-being.

There is an urgent need to eliminate mental health disparities experienced by American Indians and Alaska Natives (AI/ANs). Service providers and researchers often address these disparities by focusing on low rates of participation in Western mental health services. In part, this reflects limited understandings of the sociopolitical and historical context of AI/AN mental health problems. Furthermore, this emphasis fails to recognize the importance of emic understandings of locally resonant coping strategies, healing, and treatment. In this article, we describe (a) a study designed to address these gaps, (b) findings related to the importance of land and place, and (c) a community-university collaboration to translate these findings into meaningful change within one Diné community. Connections to the land were an important cultural strength on which to build efforts to promote mental health. Thus, effective treatment might involve more in-depth understanding of cultural processes through which healing occurs and well-being is maintained.

"An Old Way to Solve an Old Problem": Provider Perspectives on Recovery-Oriented Services and Consumer Capabilities in New Mexico.

The goal of recovery has emerged as a core value in the reformation of public and private mental health services in the last twenty years. However, definitions of recovery remain as varied as methods of implementation. Through an ethnographic lens, we examine meanings of recovery in the context of a major statewide reform of mental health services in New Mexico, focusing specifically on provider-voiced concerns regarding recovery and recovery-oriented care. We argue that the concept of recovery functions as a symbol that seemingly reconciles the long-standing tension between biological and social explanations of mental illness. Drawing upon provider perspectives, we also discuss concerns that popular rhetoric about recovery may mask some needed fundamental changes to transform the mental health system to a recovery orientation. Finally, we consider recovery from a capabilities standpoint and discuss how this view lends itself to addressing both individual and social components of mental illness.

Involvement of Youths with Autism Spectrum Disorders or Intellectual Disabilities in Multiple Public Service Systems.

The objectives of this study were to estimate the prevalence of autism spectrum disorders (ASD) and intellectual disability (ID) among youths active in at least one of five public service systems - mental health [MH], educational services for youth with serious emotional disturbance [SED], child welfare [CW], juvenile justice [JJ], and alcohol and drug services [AD].This study also reports the characteristics and patterns of system involvement among these youths. Results indicate that approximately 12% of a random sample of youths involved in these public service systems had ID or ASD. These disabilities were particularly prevalent in youth in the SED (25%), MH (13%), and CW (13%) systems and were less prevalent in the JJ and AD systems (4% each). Youths with ID or ASD were more likely than other youths to be Caucasian, have a higher socioeconomic status, and be more likely to have externalizing psychiatric and other problems. Of those with ASD or ID, approximately one third were served in more than one service system, with the MH and SED systems most likely to be serving youths with externalizing psychiatric disorders. These findings have important implications for service provision, treatment planning, and workforce development.

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.

Child anxiety disorders in public systems of care: comorbidity and service utilization.

Little is known about mental health service use among children with anxiety disorders, and even less is known about these children in public sectors of care. In this study, 1,715 children were randomly sampled from one of five public service systems. Psychiatric diagnoses were assessed with a structured interview, and standardized measures were used to assess mental health service utilization. Data from a subsample (n = 779) of youth with psychiatric disorders were analyzed. Analyses revealed that comorbidity among children with anxiety disorders was substantially higher than general population estimates. Approximately 26% of children with anxiety had a comorbid mood disorder, and 62% had a disruptive behavior disorder. Among children with anxiety disorders, those who had comorbid conditions were more likely to receive inpatient services than those without comorbidity. Comorbidity, caregiver strain, and service sector were associated with inpatient and nonspecialty service use in this group. Findings underscore the substantial comorbidity among children with anxiety disorders in public sectors of care and the potential need to adapt evidence-based interventions to meet the complex and multiple needs of these children.

Child maltreatment profiles and adjustment problems in high-risk adolescents.

The purpose of this article is to identify profiles of maltreatment experiences in a sample of high-risk adolescents and to investigate the relationship between the derived profiles and psychological adjustment. Participants are 1,131 youth between the ages of 12 and 18 years involved with publicly funded mental health and social services. Information on physical, sexual, and emotional maltreatment and psychological symptoms are obtained in interviews with adolescents and their primary caregivers. Using latent profile analysis, three maltreatment profiles are identified: "sexual+physical+emotional maltreatment," "physical+emotional maltreatment," and "low maltreatment." Adolescents in the two maltreatment profiles generally have significantly higher scores on symptom scales compared with those in the "low maltreatment" profile, but scores in the two maltreatment profiles do not differ. Findings highlight the need for agencies to identify and provide appropriate intervention for youth who experience multiple types of maltreatment.

Lessening Homelessness Among Persons with Mental Illness: A Comparison of Five Randomized Treatment Trials.

We evaluate the influence of housing, services, and individual characteristics on housing loss among formerly homeless mentally ill persons who participated in a five-site (4-city) study in the U.S. Housing and service availability were manipulated within randomized experimental designs and substance abuse and other covariates were measured with a common protocol. Findings indicate that housing availability was the primary predictor of subsequent ability to avoid homelessness, while enhanced services reduced the risk of homelessness if housing was also available. Substance abuse increased the risk of housing loss in some conditions in some projects, but specific findings differed between projects and with respect to time spent in shelters and on the streets. We identify implications for research on homeless persons with mental illness that spans different national and local contexts and involves diverse ethnic groups.

Association between mental and physical health problems in high-risk adolescents: a longitudinal study.

PURPOSE: This longitudinal study examined the relationship between mental and physical health problems in a sample of high-risk youth served in the public sector. METHODS: Participants included youth aged 9-18 years at baseline, randomly sampled from one of five public service sectors in San Diego County, California, and youths may have been active to more than one sector. Diagnoses for mood, anxiety, and disruptive disorders based on structured diagnostic interviews were determined at baseline and data regarding health-related problems were collected 2 years post-baseline. RESULTS: Mood and disruptive behavior disorders were related to cumulative health problem incidence, as well as aggregate measures of health problems and severe health problems. In addition mood disorder diagnosis was associated with higher rates of infectious diseases, respiratory problems, and weight problems. Disruptive disorder diagnosis was related to higher rates of risk behavior-related health problems. CONCLUSIONS: The present work extends the research on the relationship between mental and physical health problems to adolescents served in the public sector, who are at especially high risk for behavioral and emotional problems. Potential mechanisms by which mental health problems may impact health problems are discussed. We suggest the development of effective interagency cooperation between medical and mental health systems to improve the care of youth with comorbid mental and physical disorders.

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.

The shifting subtypes of ADHD: classification depends on how symptom reports are combined.

Research on the correlates of ADHD subtypes has yielded inconsistent findings, perhaps because the procedures used to define subtypes vary across studies. We examined this possibility by investigating whether the ADHD subtype distribution in a community sample was sensitive to different methods for combining informant data. We conducted a study to screen all children in grades 1-5 (N = 7847) in a North Carolina County for ADHD. Teachers completed a DSM-IV behavior rating scale and parents completed a structured telephone interview. We found substantial differences in the distribution of ADHD subtypes depending on whether one or both sources were used to define the subtypes. When parent and teacher data were combined, the procedures used substantially influenced subtype distribution. We conclude the ADHD subtype distribution is sensitive to how symptom information is combined and that standardization of the subtyping process is required to advance our understanding of the correlates of different ADHD subtypes.

Substance involvement among youths in child welfare: the role of common and unique risk factors.

This study examines risk factors for substance involvement for youths involved with the child welfare (CW) system. In addition to common risk factors examined in general population studies; this research examines risk factors unique to youths in the CW system, including age at entry into CW and number of out-of-home placements. Participants included 214 youths ages 13 to 18, randomly sampled from youths active to CW in San Diego County, California. Severity of substance involvement was assessed through structured diagnostic interviews determining lifetime substance use, abuse, and dependence. Hierarchical regression analyses including demographics, psychosocial variables, maltreatment history, CW placement variables, and the interaction of age at entry into CW and number of out-of-home placements revealed that both common and CW-specific risk factors were associated with the severity of youth substance involvement. Multiple-placement changes, later entry into the CW system, and multiple-placement changes at an older age are associated with higher risk for more serious substance involvement for youths in CW.

"We never used to do things this way": behavioral health care reform in New Mexico.

This column describes the first year of efforts in New Mexico to reform the behavioral health system. The process, guided by principles of cultural exchange theory, seeks to establish a "collaborative culture" among all stakeholders involved, including state agencies, consumers, families, advocates, and providers. Challenges have included inadequate system funding; insufficient development of skill sets among state personnel; underestimation of time and labor needed to address complex tasks; varying federal statutory and funder requirements for individual agencies; lack of a solid infrastructure for data collection, management, and dissemination; and clear definitions of the roles and relationships of local stakeholders to the state leadership group.

The psychological risks of Vietnam: the NVVRS perspective.

In recent years, controversy concerning the psychological consequences of service in the Vietnam war has rearisen. In this article, the Co-Principal Investigators of the National Vietnam Veterans Readjustment Study (NVVRS) provide a perspective on new findings reported by B. P. Dohrenwend et al. (2006) that addresses criticisms of the NVVRS PTSD (posttraumatic stress disorder) prevalence findings, and on a perspective that was provided by R. J. McNally (2006) in an accompanying commentary. They find that Dohrenwend et al.'s study, which evaluated empirically a variety of the critics' alternative explanations and found little support for any of them, represents a landmark contribution to the trauma field. However, they found that McNally's commentary misrepresented the history and context of the NVVRS, and then misinterpreted Dohrenwend et al.'s findings and their importance.

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.

Measures and predictors of community-based employment and earnings of persons with schizophrenia in a multisite study.

OBJECTIVE: Data from a national study of persons with schizophrenia-related disorders were examined to determine clinical factors and labor-market conditions related to employment outcomes. METHODS: Data were obtained from the U.S. Schizophrenia Care and Assessment Program, a naturalistic study of more than 2,300 persons from organized care systems in six U.S. regions. Data were collected via surveys and from medical records and clinical assessments at baseline and for three years. Outcome measures included any community-based (nonsheltered) employment, 40 or more hours of work in the past month, employment at or above the federal minimum wage, days and hours of work, and earnings. Bivariate and multiple regression analyses of data from more than 7,000 assessments tested relationships between outcomes and sociodemographic, clinical, and local labor market characteristics. RESULTS: The employment rate was 17.2%; only 57.1% of participants who worked reported 40 or more hours of past-month employment. The mean hourly wage was $7.05, and mean monthly earnings were $494.20. Employment rates and number of hours worked were substantially below those found in household surveys or in baseline data from trials of employment programs but substantially higher than those found in a recent large clinical trial. Strong positive relationships were found between clinical factors and work outcomes, but evidence of a relationship between local unemployment rates and outcomes was weak. CONCLUSIONS: Work attachment and earnings were substantially lower than in previous survey data, not very sensitive to labor market conditions, and strongly related to clinical status.

Caregiver depression and medication use by youths with ADHD who receive services in the public sector.

OBJECTIVE: This study examined caregiver depression and medication use by youths with attention-deficit hyperactivity disorder (ADHD) in the public sector. METHODS: Multivariate logistic regression models were created for 390 youths six to 17 years of age who met ADHD criteria on the Diagnostic Interview Schedule for Children (DISC) and were enrolled in a prospective study of youths served in public-sector service systems. The dependent variable was caregiver report of youth medication use for ADHD in the 12 months before the 24-month interview. RESULTS: Only 38% of youths with DISC diagnoses of ADHD were using medication. Youths whose caregivers had depression (41% of the sample) were half as likely as other youths to use medication. Younger age, public insurance, caregiver report of diagnosis, and receipt of medical, mental health, or school services also predicted use. CONCLUSIONS: Caregiver depression and its association with medication use warrant further exploration.