Changes in mental health and service use after termination of SSI benefits.

OBJECTIVE: Supplemental Security Income (SSI) benefits for a substance abuse disability were terminated by federal legislation as of January 1, 1997. This study examined the changes in mental health and in the use of mental health services two years after the legislation was implemented among individuals who had been receiving benefits under this classification. METHODS: From a random sample of 400 SSI beneficiaries in Los Angeles, 253 were interviewed at the time the legislation took effect and again at 12-month, 18-month, and 24-month follow-ups. The study subjects were characterized by income source after the legislation and by probable mental health diagnosis. Their use of mental health services was also measured. RESULTS: The mental health status of the participants remained unchanged between baseline and 24-month follow-up. The proportion who reported any use of mental health services decreased, primarily among those who continued receiving SSI benefits under a different classification. Among those who lost SSI benefits, emergency department visits and hospitalizations did not increase, and rates of outpatient visits remained the same. CONCLUSIONS: Contrary to expectations, the mental health status of individuals who had been receiving SSI benefits for a substance abuse disability did not worsen after the benefits were terminated. Local safety nets and reclassification under another disability may have mitigated the effects of the policy change. The results of this study underscore the need for longitudinal data to inform policy decisions.

A national survey of care for persons with co-occurring mental and substance use disorders.

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.

Validation of the brief instrumental functioning scale in a homeless population.

This report describes the psychometric properties of the six-item Brief Instrumental Functioning Scale (BIFS), a self-report questionnaire for measuring instrumental functioning in community populations, and the results of a study to validate the scale among homeless persons. The participants in the study were 1,509 homeless persons, of whom 1,077, or 71 percent, were seriously mentally ill, substance dependent, or both. Confirmatory factor analysis provided evidence for the unidimensionality of the items in the scale. The BIFS had high internal consistency, respectable stability, and reasonable convergent validity. The BIFS is useful for community populations when self-report data on functioning are required. Additional research is needed to develop and validate comparable scales for assessing other domains of functioning.

Changes in subjective quality of life among homeless adults who obtain housing: a prospective examination.

BACKGROUND: The aim of this present study is to examine whether overall subjective quality of life and specific domains of quality of life change among homeless adults after they become housed, and if so, what factors predict changes in satisfaction. METHODS: The data analysed here were collected through face-to-face interviews with a sample of 485 homeless adults who were interviewed as often as bi-monthly over a 16-month period. Bivariate analyses examined initial differences between three groups: homeless people who did not exit from homelessness; those with an exit from homelessness to dependent housing; and those with an exit to independent housing. Bivariate analyses also examined differences in subjective quality of life before and after an exit from homelessness among the three groups. Multivariate analyses identified predictors of changes in quality of life before and after exit. RESULTS: This study has three main findings. First, homeless people who obtained independent housing had the largest positive and significant improvements in satisfaction with overall quality of life, and in satisfaction with housing, leisure and money. Second, becoming housed was not a predictor of changes in overall quality of life perceived by homeless people, nor in their satisfaction with leisure, clothing, food, and social life. Furthermore, a positive change in housing satisfaction was not associated with all types of exits from homelessness; only a move into independent housing predicted such a change, but a move into dependent housing did not. Finally, of all the covariates included as predictors at baseline, only two variables seemed to consistently predict changes in satisfaction; namely, self-assessed general health and self-assessed self-help skills. CONCLUSIONS: This study suggested that becoming independently housed may improve some aspects of quality of life for homeless people, but not others. The results suggest that homeless people prefer to be independently housed relative to remaining homeless or staying in a dependent housing situation, but that independent housing does not necessarily improve other aspects of their lives.

Pathways to homelessness among the mentally ill.

BACKGROUND: Persons with mental illness are over-represented among the homeless relative to the general population, and mental illness is most likely one of many vulnerabilities that confer risk for homelessness. METHOD: This paper elucidates the pathways to homelessness for persons with mental illness by comparing and contrasting groups of mentally ill homeless persons, non-mentally ill homeless persons, and housed mentally ill persons drawn from RAND's Course of Homelessness (COH) study and the Epidemiological Catchment Area (ECA) survey. RESULTS: Homeless persons share childhood histories of economic and social disadvantage. The mentally ill homeless appear to have a "double dose" of disadvantage: poverty with the addition of childhood family instability and violence. Among the mentally ill homeless, those who became homeless prior to becoming mentally ill have the highest levels of disadvantage and disruption; while those who become homeless after becoming ill have an especially high prevalence of alcohol dependence. CONCLUSIONS: Mental illness may play a role in initiating homelessness for some, but is unlikely in and of itself to be a sufficient risk factor for homelessness. In addition to outreach and treatment programs for adult mentally ill homeless persons, emphasis should be placed on interventions with children and on addressing more pervasive causes of homelessness.

Quality of life of homeless persons with mental illness: results from the course-of-homelessness study.

OBJECTIVE: The quality of life of homeless persons with mental illness was compared with that of homeless persons without mental illness. METHODS: Subjective and objective quality-of-life ratings were obtained in face-to-face interviews with 1,533 homeless adults in Los Angeles, who were identified using probability sampling of people on the streets and at shelters and meal facilities; 520 subjects were tracked for 15 months. Ratings of homeless persons with and without mental illness were compared using chi square tests and regression analyses. RESULTS: Mentally ill homeless persons were significantly more likely than those without mental illness to receive Supplemental Security Income, Social Security Disability Insurance, Veterans Affairs disability benefits, or Medicaid. However, those with mental illness still fared significantly worse in terms of physical health, level of subsistence needs met, victimization, and subjective quality of life. Differences between groups in the subjective quality-of-life ratings were accounted for by modifiable factors such as income and symptoms rather than by nonmodifiable demographic characteristics. CONCLUSIONS: Interventions most likely to improve the quality of life of homeless persons with mental illness include those that stress maintenance of stable housing and provision of food and clothing and that address physical health problems and train individuals to minimize their risk of victimization. Interventions that decrease depressive symptoms might also improve subjective quality of life.

Impact of psychiatric conditions on health-related quality of life in persons with HIV infection.

OBJECTIVE: Little is known about the impact of comorbid psychiatric symptoms in persons with HIV. This study estimates the burden on health-related quality of life associated with comorbid psychiatric conditions in a nationally representative sample of persons with HIV. METHOD: The authors conducted a multistage sampling of urban and rural areas to produce a national probability sample of persons with HIV receiving medical care in the contiguous United States (N=2,864). Subjects were screened for psychiatric conditions with the short form of the Composite International Diagnostic Interview. Heavy drinking was assessed on the basis of quantity and frequency of drinking. Health-related quality of life was rated with a 28-item instrument adapted from similar measures used in the Medical Outcomes Study. RESULTS: HIV subjects with a probable mood disorder diagnosis had significantly lower scores on health-related quality of life measures than did those without such symptoms. Diminished health-related quality of life was not associated with heavy drinking, and in drug users it was accounted for by presence of a comorbid mood disorder. CONCLUSIONS: Optimization of health-related quality of life is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV. Inclusion of sufficient numbers of appropriately trained mental health professionals to identify and treat such conditions may reduce unnecessary utilization of other health services and improve health-related quality of life in persons with HIV infection.

Utilization of mental health and substance abuse services among homeless adults in Los Angeles.

OBJECTIVES: Even though psychiatric disorders are disproportionately present among the homeless, little is known about the extent to which homeless people receive treatment for those problems or the factors that are associated with receiving treatment. This article examines utilization and predictors of mental health and substance abuse treatment among a community-based probability sample of homeless adults. METHODS: The data analyzed here were collected through face-to-face interviews with 1,563 homeless individuals. Bivariate analyses examined differences between homeless men and women in (1) the prevalence of major mental illnesses and substance dependence and (2) utilization of inpatient and outpatient treatment services for those with specific diagnoses. Logistic regression analyses identified predictors of mental health treatment among those with chronic mental illness and substance abuse treatment among those with recent substance dependence. RESULTS: Two-thirds of these homeless adults met criteria for chronic substance dependence, whereas 22% met criteria for chronic mental illness, with substantial overlap between those two disorders: 77% of those with chronic mental illness were also chronic substance abusers. Only one-fifth of each of those two groups reported receiving treatment for those disorders within the last 60 days. Mental health service utilization was predicted largely by factors related to need (eg, diagnosis, acknowledgment of a mental health problem), whereas substance abuse service utilization was predicted by myriad additional factors, reflecting, in part, critical differences in the organization and financing of these systems of care. CONCLUSIONS: More attention must be directed at how to better deliver appropriate mental health and substance abuse services to homeless adults.

How the medical comorbidity of depressed patients differs across health care settings: results from the Medical Outcomes Study.

OBJECTIVE: Although depression is one of the most common problems of medical and psychiatric outpatients, it has not been clear whether the extent of medical comorbidity among depressed patients varies across major types of clinical settings in which depressed patients receive care--especially by type of treating clinician (general medical versus mental health specialty) or type of payment for services (prepaid versus fee-for-service). METHODS: The authors examined these issues using data on 1,152 adult outpatients with current depressive symptoms and a lifetime history of unipolar depressive disorder who received care in one of three health care delivery systems in three U.S. sites. RESULTS: Depressed patients had a similarly high prevalence (64.9%-71.0%) of any of eight common chronic medical conditions whether they were seen in the general medical or specialty mental health sector; however, those visiting medical clinicians had a significantly higher prevalence of the two most common chronic medical conditions, hypertension and arthritis. Among depressed patients with hypertension, those visiting the general medical sector were more likely to be taking antihypertensive medication than were those visiting the mental health specialty sector. Type of payment (prepaid versus fee-for-service) was unrelated to either prevalence or severity of comorbid medical conditions, suggesting that the typical depressed patient in all types of practices studied had medical comorbidity. CONCLUSIONS: These data suggest that clinicians in all health care settings must be prepared to encounter chronic medical conditions and complaints in the depressed patients who visit them.

Distribution of major mental disorders in an US metropolis.

This paper reviews the evolution of psychiatric nosologies in North America and the major epidemiological surveys of Mental Disorders culminating with the recently completed National Institute of Mental Health Epidemiologic Catchment Area project (NIMH-ECA). The NIMH-ECA examined the prevalence of diagnosable (DSM III) Mental disorders in 5 U.S. communities utilizing a highly structured diagnostic interview, the Diagnostic Interview Schedule (DIS). Data from the Los Angeles ECA, one of five study sites are presented with particular emphasis on cross-cultural comparison (Mexican Americans versus Non Hispanic Whites). Overall, there were only a few cross-cultural differences in prevalence of specific diagnoses. Mexico-born Mexican Americans showed a lower prevalence for most disorders examined than their U.S. born counterparts, and a subgroup of Mexican-American women (those over the age of 40) showed higher rates of phobic and dysthymic disorders as well as a greater number of functional somatic symptoms than other groups.

Use of the Mini-Mental State Examination (MMSE) in a community population of mixed ethnicity. Cultural and linguistic artifacts.

The Mini-Mental State Evaluation (MMSE) was used in an epidemiological survey of a community of mixed ethnicity (Hispanic, white non-Hispanic) as part of the Los Angeles Epidemiologic Catchment Area Program. Results of the study showed that age, educational level, ethnicity, and language of the interview influenced the number of MMSE errors. Items on which the effects of ethnicity and language were most pronounced were identified, and suggestions on ways to minimize such sociocultural artifacts are provided in efforts to improve the epidemiological significance of the instrument, particularly as it concerns cross-cultural research.

The design of the Epidemiologic Catchment Area surveys. The control and measurement of error.

Several methods are used to minimize and measure error in the NIMH Epidemiologic Catchment Area program. Sampling methods involve the inclusion of group quarters such as prisons, nursing homes, and mental hospitals in the sample frame and the use of probability sampling throughout. Interviewing, methods include use of identical diagnostic interview protocols, centralized training of interview supervisors, standard instructions to interviewers, and reinterview of a subsample by clinicians. In the area of completion, the methods include a 75% to 80% respondent completion rate, a 95% or greater completion rate for individual questions, use of informant interviews where necessary, and statistical adjustments to correct for low completion rates in some subgroups. Analytic methods include use of a computerized diagnostic algorithm, common estimation formulas on identically formatted data files, and estimation of exact variances that take account of the multistage sample design.

Development of the Spanish-language version of the National Institute of Mental Health Diagnostic Interview Schedule.

The use of the National Institute of Mental Health Diagnostic Interview Schedule (DIS) to elicit DSM-III-defined mental disorders among Hispanic respondents in the Los Angeles site of the Epidemiologic Catchment Area project required development of a Spanish translation of the instrument that would be understood readily by persons of Mexican, Puerto Rican, and Cuban origin. The translation was carried out using back translation, bilingual test respondents, a bilingual translation staff, an extensive committee of experienced bilingual clinicians as translation consultants, and revision following clinical evaluation. A study of its reliability and comparison with clinical diagnoses obtained with Spanish-speaking psychiatric outpatients indicated satisfactory equivalence of the Spanish DIS to the English version. Early international use of the Spanish DIS promises new data on the cross-cultural validity and prevalence rates of DSM-III-diagnosed disorders.