Hospitalization for mental illness in adolescents: risk groups and impact on the health care system

Psychocultural Correlates of Mental Health Service Utilization Among African American and European American Girls

Structural equation modeling was used to examine the effects of cultural factors (ethnic identity, perceived discrimination), family relations, and child problem type on mental health service utilization in a community sample of 1,480 adolescent girls (860 African American, 620 European American) between ages 15 and 17 years enrolled in the Pittsburgh Girls Study. Results revealed ethnic identity, caregiver attachment, and conduct disorder were related to service use among African American girls. Among European American girls, correlate patterns differed by clinical need. Findings highlight the need for research on health disparities to examine racially specific influences on service utilization.

An evidence synthesis of risk identification, assessment and management for young people using tier 4 inpatient child and adolescent mental health services

Background

Inpatient child and adolescent mental health services are one part of a complex system, and exist to meet the needs of young people with the greatest mental health difficulties.

Objectives

The research question was ‘What is known about the identification, assessment and management of risk (where “risk” is broadly conceived) in young people (aged 11–18 years) with complex mental health needs entering, using and exiting inpatient child and adolescent mental health services in the UK?’

Data sources

The two-phase Evidence for Policy and Practice Information and Co-ordinating Centre approach was used. In phase 1, scoping searches were made using two databases with an end date of March 2013. Phase 2 centred on the search for citations relating to the risks to young people of ‘dislocation’ and ‘contagion’. Searches were made using 17 databases, with time limits from 1995 to September 2013. Websites were searched, a call for evidence circulated and references of included citations reviewed.

Review methods

Priority risk areas for phase 2 were decided in collaboration with stakeholders including through consultations with young people and the mother of a child who had been in hospital. All types of evidence relating to outcomes, views and experiences, costs and cost-effectiveness, policies, and service and practice responses in the areas of ‘dislocation’ and ‘contagion’ for young people (11–18 years) using inpatient mental health services were considered. A staged approach to screening was used. Data were extracted into tables following guidance from the Centre for Reviews and Dissemination or tables developed for the review. Quality was assessed using appraisal checklists from the Effective Public Health Practice Project or the Critical Skills Appraisal Programme or devised by previous reviewers. No papers were excluded on the grounds of quality, and all materials identified were narratively synthesised.

Results

In phase 1, 4539 citations were found and 124 included. Most were concerned with clinical risks. In phase 2, 15,662 citations were found and 40 addressing the less obvious risks of ‘dislocation’ and ‘contagion’ were included, supplemented by 20 policy and guidance documents. These were synthesised using these categories: Dislocation: Normal Life; Dislocation: Identity; Dislocation: Friends; Dislocation: Stigma; Dislocation: Education; Dislocation: Families; and Contagion. No studies included an economic analysis or economic evaluation. The importance to stakeholders of these less obvious risks contrasted with the limited quantity and quality of research capable of informing policy, services and practice in these areas.

Limitations

Included studies were of variable quality. Data derived could not be used to inform an economic modelling of NHS costs or to analyse cost-effectiveness. Other limitations were the search for only English-language materials and the use of umbrella concepts (‘dislocation’ and ‘contagion’).

Conclusions

The less obvious risks are important, but little evidence exists to support their identification, assessment and management. This has implications for services, and a programme of research is recommended to generate new knowledge.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Predictors of admission to acute inpatient psychiatric care among children enrolled in Medicaid

This study examined acute inpatient psychiatric admissions among child Medicaid recipients with a mental health diagnosis in one Midwestern state. The authors used multivariable logistic regression to determine the demographic, clinical, and service factors associated with admissions among 51,233 Medicaid enrolled children 3-17 years old who were identified as having a mental health diagnosis. Compared to available data from other states, the overall acute admission rate was low (2.5 %). Clinical factors were the strongest predictors of hospitalization. Youths with mood, disruptive and psychotic disorder diagnoses were 14.1, 6.2, and 5.8 times more likely than other mental health beneficiaries to experience one or more acute inpatient psychiatric admissions. Other predictors of acute admission included prior hospitalization, receipt of two or more concurrent psychotropic medications, older age, and urban residence. A low rate of acute inpatient admissions may indicate successful delivery of community-based mental health services; conversely, it may suggest underservice to youths with mental health need, particularly those in rural areas. Implications for publicly funded children's mental health care are discussed.

Differences in mental health service sector utilization among African American and Caucasian youth entering systems of care programs

Differences in unmet need and access to services between African American and Caucasian youth have been established; less is known about differences in specific mental health service sectors. This study examined differences in past year outpatient, school-based, day treatment and residential/inpatient service utilization among African American and Caucasian youth (n = 3,649) entering a federally funded system of care program. Random effect logistic regression models were implemented to examine the relationship between race and past year service utilization. Analyses revealed that African American youth were less likely than Caucasian youth to have utilized school-based and residential/inpatient mental health services in the past year. Findings suggest that racial disparities exist in service use for certain types of service sectors and highlight the importance of understanding and identifying individual, family, and community factors that contribute to disparities in service utilization.

The role of race in diagnostic and disposition decision making in a pediatric psychiatric emergency service

OBJECTIVE

We investigated the influence of race/ethnicity in diagnostic and disposition decision-making for children and adolescents presenting to an urban psychiatric emergency service (PES).

METHOD

Medical records were reviewed for 2991 child and adolescent African-American, Hispanic/Latino and white patients, treated in an urban PES between October 2001 and September 2002. A series of bivariate and binomial logistic regression analyses were used to delineate the role of race in the patterns and correlates of psychiatric diagnostic and treatment disposition decisions.

RESULTS

Binomial logistic regression analyses reveal that African-American (OR=2.28, P<.001) and Hispanic/Latino (OR=2.35, P<.05) patients are more likely to receive psychotic disorders and behavioral disorders diagnoses (African American: OR=1.66, P<.001; Hispanic/Latino: OR=1.36, P<.05) than white children/adolescents presenting to PES. African-American youth compared to white youth are also less likely to receive depressive disorder (OR=0.78, P<.05), bipolar disorder (OR=.44, P<.001) and alcohol/substance abuse disorder (OR=.18, P<.01) diagnoses. African-American pediatric PES patients are also more likely to be hospitalized (OR=1.50, P<.05), controlling for other sociodemographic and clinical factors (e.g., Global Assessment of Functioning).

CONCLUSIONS

The results highlight that nonclinical factors such as race/ethnicity are associated with clinical diagnostic decisions as early as childhood suggesting the pervasiveness of such disparities.

Changes in child and adolescent inpatient psychiatric admission diagnoses between 1995 and 2000

This study examined changes in the prevalence of psychiatric diagnoses at admission among children and adolescents treated for mental health problems in psychiatric inpatient settings between 1995 and 2000. Using a large, nationwide database (MarketScan) of private health insurance claims, our sample consisted of 5,346 children under the age of 18 who received psychiatric inpatient services, out of a total of 1,723,681 covered children. Odds ratios were used to measure changes in the prevalence of specific mental health disorders between 1995 and 2000. The study identified several significant changes, most notably, that the proportion of hospitalized children treated for bipolar or eating disorder doubled between 1995 and 2000. Significant decreases were observed for adjustment, anxiety, oppositional, and substance abuse disorders. This study lends support to recent concerns that the prevalence of bipolar disorder among the youth is increasing. Further research is needed to identify the underlying reasons for these observed changes.

Mental health services use among school-aged children with disabilities: the role of sociodemographics, functional limitations, family burdens, and care coordination

OBJECTIVE

To examine the use of mental health services and correlates of receiving services among community-dwelling children with disabilities, ages 6 to 17 years.

STUDY DESIGN

Data are from the 1994 and 1995 National Health Interview Survey Disability Supplements (NHIS-D), conducted by the National Center for Health Statistics. The study sample is 4,939 children with disabilities, representing an estimated eight million children with disabilities nationwide. Parents of children under 16 years of age reported (17-year-olds self-reported) on health, emotional and behavioral problems, mental health services use, and who, if anyone, coordinated the child's health care.

PRINCIPAL FINDINGS

Among disabled children with poor psychosocial adjustment (11.5 percent), only 11.8 percent received mental health services in the past year. Multivariate logistic regression analysis showed service use was associated with poor psychosocial adjustment; communication, social, and learning-related functional impairments; public health insurance; and financial family burdens. Younger and black disabled children were less likely to receive mental health services. The odds of service use were greater with the involvement of a health professional in coordinating care, in contrast to no one or family only. Moreover, children with disabilities were more likely to use outpatient mental health services if their care was jointly coordinated by a family member and a health professional, compared to a health professional working alone. In contrast to inpatient and outpatient care, race and family burden were not associated with the likelihood of mental health counseling in special education school settings.

CONCLUSIONS

Findings indicate that only two in five disabled children with poor psychosocial adjustment receive mental health services. Differences by age, race, and insurance coverage suggest that inequalities to access exist. However, the school setting may be one in which some barriers to mental health services for disabled children are reduced. The study also shows that the involvement of health professionals in care coordination is associated with greater access to mental health care for disabled children. These findings underscore the importance of engaging both health care professionals and the family in the care process.

Variations in the costs of child and adolescent psychiatric in-patient units

BACKGROUND

Child and adolescent in-patient care is a highly specialised service, ideally requiring planning at a national level, but there are no routine data collections specifically for these services.

AIMS

To estimate unit costs for child and adolescent psychiatric in-patient units and to analyse the variations in costs between units.

METHOD

Data collection alongside a national survey with cost estimations guided by principles drawn from economic theory. Bivariate and multivariate analyses are employed to identify cost influences.

RESULTS

Fifty-eight units could provide sufficient data to allow calculation of the cost per in-patient day; mean= pound 197 (s.d.=71.6; 1999-2000 prices). The management sector, type of provision, number of rooms, capacity and location explained nearly half of the cost variation.

CONCLUSIONS

Child and adolescent psychiatric in-patient units are an expensive resource, with personnel absorbing two-thirds of the total costs. Costs per in-patient day vary fourfold and the exploration of cost variations can inform commissioning strategies.

[Mental disorders in children: the value of epidemiology]

Epidemiological research on the mental health of children is not well developed in France, as demonstrated by the very small number of publications on the subject, especially in French. The purpose of this article is to show the contribution of epidemiology to an understanding of childhood mental illness. We emphasize descriptive epidemiology (currently the most developed component), but discuss analytic and evaluative epidemiology as well. We have thus considered methodological issues related to the advantages and limitations of techniques employed, using concrete examples from international publications. For example, an extensive review of the literature reveals considerable disparity in figures on the prevalence of psychiatric disorders, chiefly because of problems of variation in definitions used and in the places and techniques of data collection (especially screening tools and diagnostic classifications). Only studies carried out in representative samples of the general population allow reliable evaluation of frequency, but these are particularly difficult and costly. The same may be said for follow-up studies, in particular those on birth cohorts, whose principle importance is that they enable the identification of predictive factors for mental disorders, starting from earliest childhood. Entire areas are currently in need of development, such as the genetic epidemiology in mental illness, clinical trials, or the evaluation of programs. Epidemiology enables the evaluation of service needs, the identification of 'risk groups' and a scientific approach to explanatory factors. In a country such as France where nearly all children are in the school system from the age of 3 years on, schools should become a place for early detection, which assumes a considerable increase in the means available and an innovative policy in the training of health personnel, especially in the area of mental health.