McAlpine D D, Mechanic D
Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ 08901-1293, USA.
Health Serv Res. 2000 Apr;35(1 Pt 2):277-92.
To examine the sociodemographic, need, risk, and insurance characteristics of persons with severe mental illness and the importance of these characteristics for predicting specialty mental health utilization among this group.
The Healthcare for Communities survey, a national study that tracks alcohol, drug, and mental health services utilization. Data come from a telephone survey of adults from 60 communities across the United States, and from a supplemental geographically dispersed sample.
Respondents were categorized as having a severe mental disorder, other mental disorder, or no measured mental disorder. Differences among groups in sociodemographics (gender, marital status, race, education, and income), insurance coverage, need for mental health care (symptoms and perceived need), and risk indicators (suicide ideation, criminal involvement, and aggressive behavior) are examined. Measures of service use for mental health care include emergency room, inpatient, and specialty outpatient care. The importance of sociodemographics, need, insurance status, and risk indicators for specialty mental health care utilization are examined through logistic regression.
The severely mentally ill in this study are disproportionately African American, unmarried, male, less educated, and have lower family incomes than those with other disorders and those with no measured mental disorders. In a 12-month period almost three-fifths of persons with severe mental illness did not receive specialty mental health care. One in five persons with severe mental illness are uninsured, and Medicare or Medicaid insures 37 percent. Persons covered by these public programs are over six times more likely to have access to specialty care than the uninsured are. Involvement in the criminal justice system also increases the probability that a person will receive care by a factor of about four, independent of level of need. The average number of outpatient visits for specialty care varies little across type of disorder, and the median number of visits (ten) is equivalent for those with a severe mental illness and those with other disorders.
Persons with severe mental illness have a high level of economic and social disadvantage. Barriers to care, including lack of insurance, are substantial and many do not receive specialty care. Public insurance programs are the major points of leverage for improving access, and policy interventions should be targeted to these programs. Problems of adequate care for the severely mentally ill may be exacerbated by the managed care trend to reductions in intensity of treatment.
研究严重精神疾病患者的社会人口统计学特征、需求、风险及保险特征,以及这些特征对于预测该群体专科心理健康服务利用情况的重要性。
“社区医疗保健调查”,一项追踪酒精、药物及心理健康服务利用情况的全国性研究。数据来自对美国60个社区成年人的电话调查,以及一个补充性的地理分布样本。
将受访者分为患有严重精神障碍、其他精神障碍或未检测出精神障碍三类。研究各类群体在社会人口统计学特征(性别、婚姻状况、种族、教育程度和收入)、保险覆盖情况、心理健康护理需求(症状及感知到的需求)以及风险指标(自杀意念、犯罪涉入和攻击行为)方面的差异。心理健康护理服务利用的衡量指标包括急诊室、住院及专科门诊护理。通过逻辑回归分析社会人口统计学特征、需求、保险状况及风险指标对专科心理健康护理利用的重要性。
与患有其他精神障碍及未检测出精神障碍的人群相比,本研究中的严重精神疾病患者中非裔美国人比例过高、未婚、男性居多、受教育程度较低且家庭收入较低。在12个月期间,近五分之三的严重精神疾病患者未接受专科心理健康护理。五分之一的严重精神疾病患者未参保,37%的患者由医疗保险或医疗补助计划承保。受这些公共项目覆盖的人群获得专科护理的可能性比未参保人群高出六倍多。参与刑事司法系统也会使一个人获得护理的概率增加约四倍,与需求水平无关。专科护理的门诊就诊平均次数在各类精神障碍中差异不大,严重精神疾病患者和其他精神障碍患者的就诊次数中位数(十次)相同。
严重精神疾病患者在经济和社会方面处于高度不利地位。包括缺乏保险在内的护理障碍巨大,许多患者未接受专科护理。公共保险项目是改善护理可及性的主要杠杆点,政策干预应针对这些项目。管理式医疗降低治疗强度的趋势可能会加剧严重精神疾病患者获得充分护理的问题。