Linda McBride

Predictors of service utilization in veterans with bipolar disorder: a prospective study

This study prospectively followed 103 bipolar patients enrolled in a VA treatment program for 1 year. Mental health service utilization was recorded and aggregated using the VA Cost Distribution Report. We hypothesized that previously reported predictors of disease severity would also predict service utilization, and that several other predictors of service utilization might also be identified. Analyses indicated that only the presence of a major affective episode at clinic intake and a recalled history of childhood physical abuse predicted mental health service utilization. Contrary to expectations, previously reported predictors of disease severity were not significant predictors. Implications for the study of economic outcome are discussed. In particular, we propose that economic outcome is a complex function of both patient and system factors, rather than simply being passively driven by disease severity.

Adaptation of a simple patient satisfaction instrument to mental health: psychometric properties

The authors describe the psychometric properties of a simple patient satisfaction self-report instrument originally developed for use in primary care patients, adapted for use in mental health clinic patients of varied educational and socioeconomic backgrounds. The instrument demonstrated a single major principal component, high internal consistency reliability, high test-retest reliability, and sensitivity to change with experimental manipulations in clinical programming. The results also indicate that patient satisfaction is unidimensional in mental health patients as it is for primary care patients.

Perceived Barriers to Health Care Access in a Treated Population

Objective: Health care access may be a significant contributor to health outcome. However, few data exist on perception of barriers by patients in treatment, and attending a clinic visit does not mean that no barriers exist. Understanding barriers for treated populations is particularly important in optimizing care for high vulnerability populations, such as those with mental illness and the elderly. Method: A structured interview, demographic questionnaire, and SF-12 were administered to 324 veterans presenting for primary care or mental health appointments at a Veterans Affairs medical center. Principle components analysis was performed and relationships to vulnerability characteristics were identified. Results: Most interview items showed modest mean levels but high variance. Responses were stable over three to six weeks. As hypothesized, perceived total barriers were greater in participants from several vulnerable populations: those receiving treatment for mental health problems, those with disabilities, and those with worse physical and mental function. Minority participants did not perceive greater barriers. An “inverted-U” relationship with age was found. Principal components analysis assigned 18 items across six clinically meaningful subscales. Participants with mental health treatment perceived greater barriers in three subscales including provider communication. Curvilinear relationships were again seen between subscales and age. Conclusions: Even individuals “in care” perceive barriers. Members of vulnerable populations, particularly those receiving mental health treatment, perceive greater barriers. Data support a multi-dimensional conceptualization of perceived barriers, and different subgroups experience different patterns of barriers.

The effects of an ambulatory collaborative practice model on process and outcome of care for bipolar disorder

Abstract Background : Bipolar disorder is a chronic mental illness that affects 1% of the population. Persons with bipolar disorder have substantial rehabilitative potential, although research has shown that such mood disorders are undertreated. Objectives : The objective was to determine the effect of a high-intensity collaborative practice ambulatory program on process and outcome of care: specifically, patient satisfaction, intensity of medication treatment, and the amount and patterns of service use. Study Design : The Bipolar Disorders Program was structured for easy patient access by assigning clinical nurse specialists as primary caregivers to each patient supported by psychiatrist backup. The first 76 patients enrolled in the Bipolar Disorders Program who completed 6 months served as the sample. A quasiexperimental study was used. A mirror image design was used where relevant measurements before admission to the Bipolar Disorders Program were compared with data during the first 6 months of enrollment. Results : Patients showed significant increases in satisfaction with care, increases in intensity of medication treatment, and trends toward decreases in neuroleptic exposure. Annualized service use data revealed significant decreases in emergency department use, psychiatric triage use, and psychiatric hospitalization days. Conclusions : These data indicated that high-intensity ambulatory treatment for bipolar disorder may have increased both treatment intensity and patient satisfaction and decreased use of costly mental health services.