Mental Health: Selected Publications

Organization, Financing, and Regulation of Services | Mental Health and Substance Abuse Coverage |
Prevention, Treatment, and Quality of Care

Organization, Financing, and Regulation of Services

"System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs." Kamala Allen, Sheila Pires, and Jonathan Brown, March 2010. This issue brief describes findings from a national survey of residential treatment facilities (RTFs) serving children and adolescents with serious behavioral health challenges. The survey explored how system of care principles are reflected in RTFs’ policies and practices as well as how RTFs are providing home- and community-based services and supports in addition to traditional offerings.

“State Variation in Out-of-Home Medicaid Mental Health Services for Children and Youth: An Examination of Residential Treatment and Inpatient Hospital Services.” Jonathan Brown, Brenda Natzke, Henry Ireys, Matthew Gillingham, and Morris Hamilton, Administration and Policy in Mental Health, August 2009 (online), July 2010 (print) (subscription only). This research investigated state variation in the use of out-of-home mental health services among children and youth enrolled in Medicaid during 2003. Medicaid claims from three states were used to describe the demographic and diagnostic characteristics of children and youth under age 22 who received mental health services in general hospitals, psychiatric hospitals, psychiatric residential treatment facilities, and other residential treatment settings and to examine their lengths of stay, repeat stays, and expenditures. Depending on the state, 6 to 13 percent of children and youth with a mental health diagnosis received out-of-home services during the year; 37 to 58 percent of these children and youth had more than one out-of-home stay. Out-of-home mental health services accounted for 21 to 75 percent of Medicaid mental health expenditures for children and youth, depending on the state. States varied considerably in lengths of stay and per beneficiary expenditures for out-of-home care. Although some similarities in out-of-home care were found across states, substantial state variation in out-of-home care warrants further research in the context of state service systems and Medicaid policies.

"Review of SoonerCare Behavioral Health Services." Melanie Au and James Verdier, September 2009. Recently, Oklahoma has done a lot to improve access to behavioral health services for children and youth under 21 years of age covered by SoonerCare, the state’s Medicaid program. This report provides a review of the SoonerCare behavioral health system, recent changes in the system, costs to the state, current processes within the system, and gaps in services.

“Pediatric Primary Care as a Component of Systems of Care.” Evaluation and Program Planning, Jonathan Brown, June 2009. Systems of care for children and youth with serious emotional disturbances have historically not included linkages with primary care. As part of a special issue of Evaluation and Program Planning focused on redefining systems of care, this article proposes that the inclusion of primary care as part of the systems of care framework has the potential to support the delivery of mental health services in primary care while also increasing the capacity of mental health specialists to address physical health problems. Although there are similarities in the core components of primary care and systems of care, a revised definition of systems of care that incorporates the goal of prevention and takes into account the broad primary care population would provide communities and policymakers with a definition that can be used to further the work of integrating the primary care and specialty mental health service sectors.

"Administration of Mental Health Services by Medicaid Agencies." James Verdier, Allison Barrett, and Sarah Davis, 2007. Medicaid spending for mental health care accounted for 26 percent of total mental health expenditures by all public and private payers combined in 2003, and 10 percent of all Medicaid dollars were spent on mental health services in that year. Medicaid now funds more than half of all mental health services administered by states and could account for two-thirds of such spending by 2017. This report, based on telephone interviews with state Medicaid directors in all 50 states and the District of Columbia between July 2005 and February 2006, provides state-by-state comparative information on how Medicaid and mental health agencies are structured, the degree and extent of their collaboration, how they share authority, and how Medicaid mental health services are funded.

“State Regulation of Residential Facilities for Children with Mental Illness.” Henry Ireys, Lori Achman, and Ama Takyi, 2006. There is little national information on the policies and procedures used by states to regulate residential treatment facilities for adults and children with mental illness. As a result, policymakers and program administrators face major difficulties in determining both the effectiveness of current policies and the potential need for new policies that are responsive to emerging trends in mental health care. Two new reports, based on a 2003 survey of state officials, provide the most accurate national data available concerning methods that states use to license and regulate residential facilities for adults and children with mental illness. Findings demonstrated that organizations operating facilities for children and adults with mental illness typically faced a complex regulatory environment. In addition, many states lack ready access to important data about these residential facilities.

"State Regulation of Residential Facilities for Adults with Mental Illness." Henry Ireys, Lori Achman, and Ama Takyi, 2006. There is little national information on the policies and procedures used by states to regulate residential treatment facilities for adults and children with mental illness. As a result, policymakers and program administrators face major difficulties in determining both the effectiveness of current policies and the potential need for new policies that are responsive to emerging trends in mental health care. Two new reports, based on a 2003 survey of state officials, provide the most accurate national data available concerning methods that states use to license and regulate residential facilities for adults and children with mental illness. Findings demonstrated that organizations operating facilities for children and adults with mental illness typically faced a complex regulatory environment. In addition, many states lack ready access to important data about these residential facilities.

“Public Financing of Home and Community Services for Children and Youth with Serious Emotional Disturbances: Selected State Strategies.” Henry Ireys, Sheila Pires, and Meredith Lee, June 2006. Strengthening the financing of intensive home and community services for youth with serious emotional disorders (SEDs) brings into play a complex set of policy issues, payment mechanisms, and service system reforms. This report presents critical background information on these topics. It includes examples of effective partnerships between agencies that serve youth with SED, describes the background and policy context for innovative programs in selected states, and identifies the strengths and weaknesses of four major financing mechanisms: HCBS waivers, the Medicaid rehabilitation option, case rates for high-risk populations, and provisions in the Tax Equity and Fiscal Responsibility Act (TEFRA), also known as the Katie Beckett provision. Finally, the report presents a synthesis of findings and discusses their implications for states that are planning to develop demonstration projects, authorized under the 2005 Deficit Reduction Act, to strengthen the financing of intensive home and community services for youth with SEDs and their families.

"Medicaid Financing of State and County Psychiatric Hospitals. Special Report." Debra Draper, Megan McHugh, Lori Achman, and Sylvia Kuo, 2003. Despite the perception that few people are served by public psychiatric hospitals, they play a critical role in the continuum of care for people with mental illness. Although the capacity of these hospitals has diminished as a result of deinstitutionalization, they continue to serve people with severe and chronic mental illness who do not have the resources to seek care elsewhere, as well as a forensic population with mental illness. Furthermore, Medicaid is funding an increasing share of their operations, with states accessing a variety of Medicaid funding sources, including Disproportionate Share Hospital payments, Institutions for Mental Diseases optional services, and Medicaid managed care.

"Integrating Alcohol and Drug Treatment into a Work-Oriented Welfare Program: Lessons from Oregon." Gretchen Kirby, LaDonna Pavetti, Jacqueline Kauff, and John Tapogna, June 1999. Draws on the experiences of Oregon, where welfare offices have addressed alcohol and drug problems since 1992, to help states develop ways to include treatment in a work-oriented welfare environment. Key factors for success include strong leadership at the state level as well as collaboration and communication between the existing welfare and alcohol and drug treatment systems.

Mental Health and Substance Abuse Coverage

"How Are the Experiences of Individuals with Severe Mental Illness Different from Those of Other Medicaid Buy-In Participants?" Working with Disability, Work and Insurance In Brief #11. Su Liu and Sarah Croake, August 2010. This issue brief presents the health and employment experiences of Medicaid Buy-In participants with severe mental illness in comparison to those of other Medicaid Buy-In participants. These descriptive statistics of medical expenditures, earnings, and earnings growth show that Buy-In participants with severe mental illness had lower medical expenditures and were more likely to be employed and to increase their earnings over time, at least in the short to medium term.

“Establishing and Maintaining Medicaid Eligibility Upon Release from Public Institutions.” Audra Wenzlow, Henry T. Ireys, Carol Irvin, and Matthew Hodges, June 2010. This report describes an evaluation of Oklahoma’s efforts to develop and implement a model program to ensure that eligible individuals with mental illness were enrolled in Medicaid at discharge from state prisons and institutions for mental diseases.

"Implementation of Mental Health Parity: Lessons From California." Margo L. Rosenbach, Timothy K. Lake, Susan R. Williams, and Jeffrey A. Buck, Psychiatric Services, December 2009. In 2000, California legislated parity coverage for mental health care. This article reviews the experiences of state health plans, providers, and consumers between 2000 and 2005 in implementing parity and discusses implications for the 2008 federal parity law. California’s experiences suggest that federal policymakers should consider monitoring health plan performance related to access and quality, in addition to monitoring coverage and costs; examining the breadth of diagnoses covered by health plans; and mounting a campaign to educate consumers about their insurance benefits.

"Health Care Survey of DoD Beneficiaries 2008 Annual Report." Kristin Andrews, Katherine Bencio, Jonathan Brown, Leslie Conwell, Cheryl Fahlman, and Eric Schone, August 2008. This annual report describes results from a worldwide survey of beneficiaries eligible for health care coverage through the military health system (MHS). The survey covered beneficiaries’ ratings of their health care and health plan, access to care, choice of health plan, and other relevant subjects. Results were compared to benchmarks from civilian health plans. Fewer than 10 percent of beneficiaries report fair or poor mental health, but one-sixth report a need for treatment or counseling. Need for treatment or counseling differs by gender, race, and education. Eighty percent of parents told by a doctor that their child needed to see a mental health specialist reported their child had seen such a specialist. Among those who did not, the most often cited reason (18 percent) was inability to find such a specialist.

"National Estimates of Mental Health Insurance Benefits." Myles Maxfield, Lori Achman, Jeffrey A. Buck, and Judith L. Teich, Journal of Behavioral Health Services and Research, May 2006. This article presents estimates of the proportion of the U.S. population that had mental health benefits in 1999, the extent of their coverage, and the proportion enrolled in health plans subject to the Mental Health Parity Act of 1996 (MHPA). Over three-quarters (76 percent) had mental health benefits as part of their health insurance. Approximately 18 percent had no such benefits; for the remaining 6 percent, mental health benefits could not be determined. Of the 18 percent with no mental health benefits, 84 percent also had no health insurance; the remainder (16 percent) had health insurance that did not cover mental health benefits. Estimates of the generosity of coverage indicate that for 44 percent of the population, benefits included prescription drugs as well as at least 30 inpatient days and 20 outpatient visits for psychiatric care. For 12 percent of the population, benefit generosity could not be determined. Finally, study results suggest that the MHPA affected only 42 percent of the U.S. population.

"Effects of the Vermont Mental Health and Substance Abuse Parity Law." Margo Rosenbach, Tim Lake, Cheryl Young, Wendy Conroy, Brian Quinn, Julie Ingels, Brenda Cox, Anne Peterson, and Lindsay Crozier., 2003. This study looks at the first two to three years of parity for mental health and substance abuse benefits in Vermont and concludes that parity was achieved in the state. Increased use of managed care helped make parity affordable but may have reduced access and utilization for some services and beneficiaries. Parity did not appear to have an effect on the insurance market, although limited knowledge of the law complicated implementation for employers, providers, and consumers.

"A Snapshot of the Implementation of California's Mental Health Parity Law." Tim Lake, Alicia Sasser, Cheryl Young, and Brian Quinn, February 2002. Notes that, in the first year of implementation of a new mental health parity law in California, benefits for mental health services expanded with no apparent effects on the purchase of health insurance. Stakeholders interviewed for the study reported that premiums did not increase substantially in the first year, as some had feared, and employers did not drop coverage or switch to self-insured plans in order to avoid the law’s mandate.

Prevention, Treatment, and Quality of Care

"Medicaid Beneficiaries Using Mental Health or Substance Abuse Services in Fee-for-Service Plans in 13 States, 2003." Henry T. Ireys, Allison L. Barrett, Jeffrey A. Buck, Thomas W. Croghan, Melanie Au, and Judith L. Teich, Psychiatric Services, September 2010 (subscription required). This study examined Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states in 2003, concluding that they entered general hospitals and visited emergency rooms far more frequently than other beneficiaries.

"Using Medical Records to Supplement a Claims-Based Comparative Effectiveness Analysis of Antidepressants." Thomas W. Croghan, Dominick Esposito, Gregory Daniel, Peter Wahl, and Michael A. Stoto, Pharmacoepidemiology and Drug Safety, August 2010 (subscription required). This article presents findings from a study to determine if medical information in patient charts could offer clinical details that would help interpret a claims-based comparative effectiveness study of selective serotonin reuptake inhibitors (SSRIs).

"Integrating Mental Health Treatment into the Patient Centered Medical Home," Thomas W. Croghan and Jonathan D. Brown, June 2010. This paper identifies the conceptual similarities in and differences between the PCMH and current strategies used to deliver mental health treatment in primary care. The paper finds that even though adoption of the PCMH has the potential to enhance delivery of mental health treatment in primary care, several programmatic and policy actions are needed to facilitate integration of high quality mental health treatment within a PCMH.

“Therapeutic Alliance in Pediatric Primary Care: Preliminary Evidence for a Relationship with Physician Communication Style and Mother’s Satisfaction.” Lawrence S. Wissow, Jonathan D. Brown, and Janice Krupnick, Administration and Policy in Mental Health and Mental Health Services Research, February/March 2010 (subscription only). This article found it is possible to use a variation of the Vanderbilt Therapeutic Alliance Scale (VTAS) to rate parent-provider interactions in pediatric primary care. Measuring therapeutic alliance may be a useful tool in evaluating interventions to improve the delivery of mental health services in primary care because of its potential specificity as a marker of mental health-related outcomes.

"How Many Nursing Home Residents Live with a Mental Illness?" Ann D. Bagchi, James M. Verdier, and Samuel E. Simon, Psychiatric Services, July 2009. A number of data sets can be used to estimate the size of the nursing home population with mental illness; however, estimates vary because of differences in data collection. The 2004 National Nursing Home Survey (NNHS) estimates that 6.8 percent of nursing home residents had a primary diagnosis of mental illness in that year (6.0 percent of those 65 and older, and 12.9 percent of those under 65). Comparable populations in the Medicaid Analytic eXtract (MAX) data set had fewer mental illness diagnoses, and those in the nursing facility Minimum Data Set (MDS) had more. The authors conclude that the estimates from the NNHS are more reliable, but they are available only at the national level. State- and facility-level estimates would have to be generated with the MDS or MAX data sets, with users being aware of differences in recorded diagnoses among the three, especially the relatively limited diagnoses in the MAX and imprecise diagnoses in the MDS.

"Discussion of Sensitive Health Topics with Youth During Primary Care Visits: Relationship to Youth Perceptions of Care." Jonathan D. Brown and Lawrence S. Wissow, Journal of Adolescent Health, January 2009. Youth have concerns about sensitive health topics, including drugs, sex, and mental health. Providers often perceive that youth are uncomfortable discussing these topics and do not address these concerns. This study found that youth who discussed sensitive topics with their primary care provider during routine visits were more likely to feel their provider understood their problems, eased their worries, and allowed them to take an active role in their treatment. These positive perceptions of care may lead to improved treatment adherence and help-seeking in the future, encouraging primary care providers to routinely discuss sensitive health topics with youth in a confidential and sensitive manner.

"Discussion of Maternal Stress During Pediatric Primary Care Visits." Jonathan D. Brown and Lawrence S. Wissow, Ambulatory Pediatrics, November-December 2008. Maternal stress interferes with mothers’ ability to parent and has a negative impact on the physical and mental health of children. Pediatric primary care providers often fear that mothers will react negatively to discussion of their own emotional problems, and therefore, do not address maternal stress. This study found that mothers were more satisfied with their child’s provider when the provider discussed maternal stress during routine visits. The findings may encourage providers to inquire about maternal stress during pediatric visits.

"Disagreement in Parent and Primary Care Provider Reports of Mental Health Counseling." Jonathan D. Brown and Lawrence S. Wissow, Pediatrics, December 2008. Pediatricians and family practitioners commonly report providing counseling for child mental health problems. However, the quality and content of mental health counseling delivered in pediatric primary care is not well understood. This study found that parents did not report receiving mental health counseling during 74.8 percent of visits in which the provider reported delivering mental health counseling. Providers who felt more burden by treating mental health problems or who reported that mental health specialists were less accessible were more likely to deliver counseling that parents failed to perceive as mental health treatment. Strategies may be needed to improve the quality of mental health counseling in pediatric primary care.

"A Common Factors Approach to Improving the Mental Health Capacity of Pediatric Primary Care." Larry Wissow, Bruno Anthony, Jonathan Brown, Susan DosReis, Anne Gadomski, Golda Ginsburg, and Mark Riddle, Administration and Policy in Mental Health and Mental Health Services Research, July 2008. Strategies used to treat children's mental health problems in primary care have several limitations. This article proposes a new clinical model for delivering mental health services in pediatric primary care and suggests that physicians can efficiently learn a core set of treatment skills and apply them to a broad range of mental health problems. The authors review how implementation of this model would affect the delivery, organization, and funding of pediatric primary care and propose a research agenda to test the model.

"Receiving Advice About Child Mental Health From a Primary Care Provider: African American and Hispanic Parent Attitudes." Jonathan D. Brown, Lawrence S. Wissow, Ciara Zachary, and Benjamin L. Cook, Medical Care, November 2007. African American and Hispanic youth with mental health problems are less likely than their Caucasian counterparts to receive mental health services. Primary care providers are often the source of mental health care for children and may play a role in reducing disparities. This research investigated parent attitudes associated with receiving advice about child mental health in primary care and whether attitudes differed according to race and ethnicity during 773 visits to 54 providers in 13 clinics. Hispanics were more likely than non-Hispanics to agree that primary care providers should treat child mental health and were more willing to allow their child to receive medications or visit a therapist for a mental health problem if recommended by the provider. African American parents were significantly less willing than Caucasians and Hispanics to allow their child to receive medications for mental health but did not differ in their willingness to visit a therapist. These findings suggest that African American parents are generally as willing as Caucasian parents to have their child’s mental health needs addressed in primary care and that primary care may be a particularly good point of intervention for Hispanic youth with mental health problems.

"Quality Care for Children with ADHD: The Role of Primary Care Physicians." Quality Care for Special Kids: Profiles of Children with Chronic Conditions and Disabilities, Update #6. Stephanie Peterson, Shanna Shulman, and Henry Ireys, April 2007. This brief, the sixth in a series on critical issues involved in caring for children with special health care needs, notes that 40 percent of children with special health care needs enrolled in commercial health insurance plans have an emotional or behavioral disorder. Of these children, 34 percent have a diagnosis of attention deficit hyperactivity disorder (ADHD) alone, and an additional 22 percent have ADHD along with another chronic condition. Children with ADHD receive most of their care from primary care clinicians and use significantly more health care services than do children without ADHD. The brief lists some newly developed health care tools that health plans can use to help ensure that treatment for these children is delivered efficiently and appropriately in primary care offices.

"Treating Emotional and Behavioral Disorders in Children and Adolescents." Quality Care for Special Kids: Profiles of Children with Chronic Conditions and Disabilities, Update #3. Shanna Shulman, Henry Ireys, and Stephanie Peterson, December 2006. This brief, the third in a series on critical issues involved in caring for children with special health care needs, notes that 40 percent of these children enrolled in commercial health plans need treatment for emotional or behavioral disorders. Although health plans have been working to ensure that effective treatments are covered, 11 percent of parents are dissatisfied with the health benefits their children receive.

“Screening for Substance Use in Pregnancy: A Practical Approach for the Primary Care Physician." Ira Chasnoff, Kim Neuman, Craig Thornton, and M. Angela Callaghan, Journal of Obstetrics and Gynecology, March 2001. Suggests that primary care physicians can ask three questions in the context of a prenatal health evaluation to target women for referral to a full clinical assessment for drug and alcohol use.

"Providing Mental Health Services to TANF Recipients: Program Design Choices and Implementation Challenges in Four States." Michelle K. Derr, Sarah Douglas, and LaDonna Pavetti, August 2001. Profiles the efforts of four states—Florida, Oregon, Tennessee, and Utah—to address welfare recipients' mental health conditions, which are often barriers to employment. Notes that these conditions, which occur at substantially higher rates in welfare recipients than in the general population, can be addressed in a variety of ways. Although each state used a different approach to addressing these conditions, there is no evidence to suggest that any one model is better than another.