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PubMed1995

Social consequences of psychiatric disorders, I: Educational attainment.

OBJECTIVE: This is the first in a series of investigations of the social consequences of psychiatric disorders based on the National Comorbidity Survey. Data on the relationship between preexisting psychiatric disorders and subsequent educational attainment are presented. METHOD: The National Comorbidity Survey is a nationally representative survey of 8,098 respondents in the age range 15-54 years. A subsample of 5,877 respondents completed a structured psychiatric interview and a detailed risk factor battery. Diagnoses of DSM-III-R anxiety disorders, mood disorders, substance use disorders, and conduct disorder were generated, and survival analyses were used to project data on school terminations to the total U.S. population. RESULTS: Early-onset psychiatric disorders are present in more than 3.5 million people in the age range of the National Comorbidity Survey who did not complete high school and close to 4.3 million who did not complete college. The most important disorders are conduct disorder among men and anxiety disorders among women. The proportion of school dropouts with psychiatric disorders has increased dramatically in recent cohorts, and persons with psychiatric disorders currently account for 14.2% of high school dropouts and 4.7% of college dropouts. CONCLUSIONS: Early-onset psychiatric disorders probably have a variety of adverse consequences. The results presented here show that truncated educational attainment is one of them. Debate concerning whether society can afford universal insurance coverage for the treatment of mental disorders needs to take these consequences into consideration.

Adolescent↗
PubMed1994

Paying for mental health and substance abuse care.

Fifty-four billion dollars was spent on alcohol/drug abuse and mental health treatment in 1990. These expenditures were concentrated in the area of inpatient psychiatric care and on persons with severe mental health and substance abuse problems. The data on expenditure patterns for mental health and substance abuse care suggest that successful health care reform in this area must implement mechanisms for controlling inpatient utilization and managing the care of persons with the most severe disorders.

Cost Control↗
PubMed2002

Does U.S. federal policy support employment and recovery for people with psychiatric disabilities?

Evidence suggests that a high percentage of people with a psychiatric disability can recover--find meaningful work, develop positive relationships, and participate fully in their communities. Evidence also suggests that work is an essential component of recovery. However, few people with a serious psychiatric disability are actually employed and most of those who are employed work only part-time at barely minimum wages. To assess the impact of federal programs such as Social Security Disability Insurance, vocational rehabilitation, medical insurance, and psychiatric services upon employment, we conducted a qualitative study of 16 employed and 16 unemployed individuals with psychiatric disabilities. All of our participants had disabilities severe enough to qualify them for Social Security Disability benefits. They told us that current federal policies and practices encouraged employment and integration of only a few participants, in a particular stage of their recovery, and placed significant barriers in the employment path of others.

Adult↗
PubMed1993

Characteristics of youths identified from a psychiatric case register as first-time users of services.

OBJECTIVE: The study examined associations between sociodemographic factors and first-time use of mental health services by children and adolescents, including whether the patterns differ by age at first treatment contact. METHODS: The authors examined sociodemographic characteristics of 4,949 youths listed on a psychiatric case register in Monroe County, New York, who were under age 19 when first seen for public mental health treatment between 1987 and 1989. Data on race and type of insurance for patients in the county's four catchment areas were compared with 1980 census data. Insurance was categorized as public (such as Medicaid) or private and was used as a proxy for socioeconomic status. RESULTS: Both minority and publicly insured youths of low socio-economic status were overrepresented in the treatment population in relation to their numbers in the county, although publicly insured youths from the poorest catchment area were underrepresented in the treatment population. Among children (ages five to 12) in the treatment population, males outnumbered females by 2 to 1, but among adolescents (ages 13 to 18), the numbers were similar. Among minority groups, children receiving first-time mental health services were more likely to have public insurance. Minority adolescents were somewhat more likely to be privately than publicly insured.

Adolescent↗
PubMed1994

A new day: strategies for managing psychiatric and substance abuse benefits.

Rising health care costs for psychiatric and substance abuse disorders have led to a marked increase in attempts by managed care organizations to address this issue. This article presents a number of innovative strategies that may help reduce overall health care costs by addressing the problem of undiagnosed and/or untreated psychiatric and substance abuse disorders.

Alcohol Drinking↗
PubMed2000

The history, economics, and financing of mental health care. Part 3: The present.

1. Health care system changes, particularly the managed care plans, are altering mental health practices in significant ways. The autonomy and independent judgment of clinicians are being limited. 2. Market expansion created child and adolescent hospitals in the private sector. This market was very favorable to growth because of the great ambiguity in diagnosis and treatment, and the nonexistence of commitment laws for this population. 3. While insurance coverage for psychiatric diagnoses has expanded, more affluent people, with good employment possibilities, still have better insurance than poor individuals.

Hospitalization↗
PubMed1989

Factors associated with premature termination from outpatient treatment.

A variety of demographic and clinical data collected on 142 new patients treated in an adult psychiatric outpatient clinic were analyzed to determine factors that discriminated between patients who terminated treatment prematurely during the first eight months of therapy and those who did not. High levels of paranoid ideation, lack of health insurance, and living less than 15 miles from the clinic were significantly associated with premature termination. Those factors were combined with three others--substance abuse, divorced marital status, and absence of fee reduction--in a probit regression model that correctly predicted the incidence of premature termination in 75 percent of the patients. The results suggest that patients who may be at risk for premature termination of outpatient therapy can be identified early in the course of their treatment.

Adolescent↗
PubMed1980

Measuring psychiatric utilization: the rubber yardstick.

The author suggests that measuring utilization of benefits for nervous and mental disorders by using the percent of total benefits paid is imprecise because even small changes in the much larger portion of benefit payments that are attributable to nonpsychiatric services can make it appear that the level of psychiatric utilization has changed. His preferred measure is a calculation of covered charges attributable to psychiatric care per each person covered under the plan. The author illustrates his points by showing that, when properly calculated, psychiatric utilization under the Civilian Health and Medical Program of the Uniformed Services is much lower than that under many other plans.

Humans↗
PubMed1993

The case for a services-based approach to payment for mental illness under national health care reform.

In this position paper drafted by the committee on psychopathology of the Group for the Advancement of Psychiatry, the authors discuss merits and disadvantages of three different approaches to equitable coverage of mental illness: coverage for selected psychiatric diagnoses, coverage based on severity of impairment, and coverage of services. They believe that coverage of selected disorders has political appeal but is discriminatory and arbitrary; it is also impractical because clinicians may overdiagnose conditions covered by insurance and underdiagnose excluded conditions. Coverage based on severity of impairment, or disability, has similar limitations. The authors believe services should be the principal basis for coverage, as under general medical insurance. The approach is nondiscriminatory, and costs can be controlled through such means as managed care, changes in the payment system, or benefit design.

Community Mental Health Services↗
PubMed2000

Translating behavioral health services research into benefits policy.

This article uses a 4-pronged statistical approach to examine the impact of a mental health carve-out at a major employer. To examine net financial impact of the carve-out, the authors perform a pre-post, multivariate regression analysis of changes in costs. Using a random-effects model, the authors explore the ultimate financial impact of the carve-out for patients and for the firm. Using a multinomial logistic regression, they examine differing program effects by intensity of use. A fixed-effects negative binomial regression models the episodic nature of outpatient care, controlling for patient-specific unobserved characteristics that influence health care utilization. The carve-out slightly reduced overall mental health costs and utilization while expanding entry-level access to routine services. At the same time, the specific carve-out shifted financial burdens from the firm onto high-utilization patients. Therefore, this carve-out appears poorly suited to the care of individuals experiencing severe and debilitating psychiatric disorders.

Adult↗
PubMed1999

Health insurance, health reform, and outpatient mental health treatment: who benefits?

This research examines how extending health insurance coverage to the previously uninsured impacts outpatient mental health treatment use among adults with different needs. Using data from the Epidemiologic Catchment Area Study and the 1987 National Medical Expenditure Survey, I develop simulations based on estimates of treatment demand. I find that insurance substantially increases demand by the mentally ill, but increased coverage alone cannot meet their treatment needs. Those in better mental health account for significant proportions of additional demand when coverage is expanded. Policies intended to increase access to mental health treatment among targeted groups should carefully consider the costs of increased use by other people.

Adult↗