Mimi M. Kim

Access to Medical Care Among Persons With Psychotic and Major Affective Disorders

OBJECTIVE People with serious mental illness have higher mortality rates than the general population, and this difference is not explained by such causes as suicide or accidents. This study therefore examined access and barriers to medical care among persons with serious mental illness. METHODS Using a nationally representative sample, the authors examined access and barriers to medical care among individuals reporting psychotic and mood disorders. The National Health Interview Survey (NHIS) and NHIS-Disability Component for 1994 and 1995 were merged to provide a sample of 156,475 people over age 18. Individuals with psychotic disorders, bipolar disorder, or major depression were compared with persons without mental disorders on the following outcomes: having a primary care physician, being unable to get needed medical care, being unable to get a needed prescription medication, and delaying medical care because of cost. RESULTS Persons with psychotic disorders (odds ratio [OR]=.55, 95% confidence interval [CI]=.44-.69) and bipolar disorder (OR=.74, CI=.56-.98) had significantly reduced odds of having a primary care physician compared with people without mental disorders. For any barriers to care, persons with psychotic disorders, bipolar disorder, or major depressive disorder had greatly increased odds (ORs=2.5-7.0) of reporting difficulties in accessing care. CONCLUSIONS Persons with psychotic disorders and bipolar disorder reported markedly more difficulty in obtaining a primary care physician and greater barriers to care than the general population. Interventions are needed to improve provision of primary medical care to this population.

Healthcare barriers among severely mentally ill homeless adults: evidence from the five-site health and risk study.

AbstractFew studies have examined barriers to physical and mental healthcare among homeless mentally adults. Methods This study examined physical and mental healthcare barriers reported by 154 recently homeless mentally ill persons. Results Practical concerns (e.g. transportation and cost) were key components of barriers to accessing general medical care among uninsured men with poorer overall mental health, PTSD, and STD infections. Perceived stigma was an important component of mental healthcare barriers reported most frequently by those with greater psychiatric symptoms. Conclusion Focusing on individual characteristics underlying barriers to healthcare may lead to better interventions for improving access to needed care.

Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child.

Abstract Aims To assess the safety of buprenorphine compared with methadone to treat pregnant women with opioid use disorder. Methods We searched PubMed, Embase and the Cochrane Library from inception to February 2015 for randomized controlled trials (RCT) and observational cohort studies (OBS) that compared buprenorphine with methadone for treating opioid‐dependent pregnant women. Two reviewers assessed independently the titles and abstracts of all search results and full texts of potentially eligible studies reporting original data for maternal/fetal/infant death, preterm birth, fetal growth outcomes, fetal/congenital anomalies, fetal/child neurodevelopment and/or maternal adverse events. We ascertained each studys risk of bias using validated instruments and assessed the strength of evidence for each outcome using established methods. We computed effect sizes using random‐effects models for each outcome with two or more studies. Results Three RCTs (n = 223) and 15 cohort OBSs (n = 1923) met inclusion criteria. In meta‐analyses using unadjusted data and methadone as comparator, buprenorphine was associated with lower risk of preterm birth [RCT risk ratio (RR) = 0.40, 95% confidence interval (CI) = 0.18, 0.91; OBS RR = 0.67, 95% CI = 0.50, 0.90], greater birth weight [RCT weighted mean difference (WMD) = 277 g, 95% CI = 104, 450; OBS WMD = 265 g, 95% CI = 196, 335] and larger head circumference [RCT WMD = 0.90 cm, 95% CI = 0.14, 1.66; OBS WMD = 0.68 cm, 95% CI = 0.41, 0.94]. No treatment differences were observed for spontaneous fetal death, fetal/congenital anomalies and other fetal growth measures, although the power to detect such differences may be inadequate due to small sample sizes. Conclusions Moderately strong evidence indicates lower risk of preterm birth, greater birth weight and larger head circumference with buprenorphine treatment of maternal opioid use disorder during pregnancy compared with methadone treatment, and no greater harms.

Can shelter-based interventions improve treatment engagement in homeless individuals with psychiatric and/or substance misuse disorders? A randomized controlled trial

Background:High proportions of homeless individuals have mental illness and substance use disorders. Few of these individuals engage in consistent treatment, although they are likely to benefit from it. Shelter-based interventions to help this population engage in treatment have not been studied in a rigorous manner. Objectives:We sought to evaluate the effectiveness of a shelter-based intervention, including intensive outreach by a psychiatric social worker and availability of weekly psychiatrist visits with continuity of care to engage homeless individuals with psychiatric and substance use problems. Research Design:This was a randomized controlled trial. Subjects:A total of 102 individuals were referred to a shelter-based psychiatric clinic. Measures:The primary outcome measure was first appointment attendance at a community mental health center (CMHC). Secondary outcome measures were attendance at second and third CMHC appointments, participation in a substance abuse program, and employment and housing status at shelter exit. Results:Individuals receiving the intervention were more likely to attend ≥1 CMHC appointment (64.7% versus 37.3%, P = 0.006) and to participate in a substance abuse program (51.4% versus 12.5%, P = 0.0006) than those in the control group. There was a trend towards being more likely to attend 2 CMHC visits (33.3% versus 17.7%, P = 0.083), but no significant differences in attending 3 visits, being employed, or having housing. Conclusions:Shelter-based interventions hold promise for improving treatment engagement in homeless populations with psychiatric and substance use problems. Further study should address how to foster care beyond an initial CMHC appointment and clarify key program components using a wider range of outcome measures.

Psychiatric advance directives: a tool for consumer empowerment and recovery.

Individuals with psychiatric disabilities identify choice and self-direction as central elements of recovery. During times of psychiatric crisis people may experience a frightening loss of choice and self-direction, which can be damaging and traumatic. Psychiatric advance directives (PADs) are legal documents created to address this loss of autonomy and choice during crises by allowing individuals to communicate in the present wishes for care during a future crisis. This paper examines the ways in which PADs support and can be a tool for recovery and discusses future recovery-oriented directions for PAD research and intervention.

Trauma and post-traumatic stress among homeless men : A review of current research

ABSTRACT As the prevalence of homelessness among men increases, the impact of trauma and post-traumatic stress disorder in the lives of homeless men warrants attention. We will review research and clinical reports on the impact of traumatic event exposure, the antecedents and consequences of traumatic events, and homelessness among males in order to begin to develop scientific, public health, and social policy answers to several questions. The nascent clinical and scientific literature provides evidence of the need for prospective studies of the etiology, epidemiology, course, and prevention of post-traumatic stress disorder among males who are at risk for or in the early stages of homelessness. We attempt to summarize, categorize, and suggest important variables and causal relationships that can inform future research studies and interventions in order to contribute to the growth of this underdeveloped and important knowledge base.

Front line workers’ attitudes towards psychiatric advance directives

Studies have begun to explore provider attitudes’ toward psychiatric advance directives (PADs) and how those attitudes are related to provider characteristics. The study gathered attitudinal data from a sample of 193 social workers serving mentally ill adults. Social workers with pro-healthcare power of attorney (HCPA) attitudes were likely to have prior experience with an HCPA and to believe that involuntary treatment violates the NASW Code of Ethics. Social workers are more favorable of HCPAs than advance instructions. The findings suggest that clinical experiences with PADs may positively impact social worker’s perceptions of the law.

Connecting communities to health research: development of the Project CONNECT minority research registry.

INTRODUCTION Prevention and treatment standards are based on evidence obtained in behavioral and clinical research. However, racial and ethnic minorities remain relatively absent from the science that develops these standards. While investigators have successfully recruited participants for individual studies using tailored recruitment methods, these strategies require considerable time and resources. Research registries, typically developed around a disease or condition, serve as a promising model for a targeted recruitment method to increase minority participation in health research. This study assessed the tailored recruitment methods used to populate a health research registry targeting African-American community members. METHODS We describe six recruitment methods applied between September 2004 and October 2008 to recruit members into a health research registry. Recruitment included direct (existing studies, public databases, community outreach) and indirect methods (radio, internet, and email) targeting the general population, local universities, and African American communities. We conducted retrospective analysis of the recruitment by method using descriptive statistics, frequencies, and chi-square statistics. RESULTS During the recruitment period, 608 individuals enrolled in the research registry. The majority of enrollees were African American, female, and in good health. Direct and indirect methods were identified as successful strategies for subgroups. Findings suggest significant associations between recruitment methods and age, presence of existing health condition, prior research participation, and motivation to join the registry. CONCLUSIONS A health research registry can be a successful tool to increase minority awareness of research opportunities. Multi-pronged recruitment approaches are needed to reach diverse subpopulations.

Participating in Research: Attitudes within the African American Church

We assessed associations between pastor and congregant characteristics and congregant attitudes about research participation among African American churches. Respondents shared their attitudes regarding how willing, ready, and confident they were about research participation. The outcome measure, the index of research preparedness, summed responses across the domains of willingness, readiness, and confidence. Pastor age and pastor educational attainment were independently associated with a congregants’ higher index of research preparedness. Young and educated pastors were significantly associated with congregant attitudes about participation preparedness, a finding that highlights the importance of the pastor regarding congregant research participation decisions.

Examining Characteristics of Congregation Members Willing to Attend Health Promotion in African American Churches

Background. Although churches are an important partner for improving health within the African American community, it is not known how congregants are best reached by health promotion activities and thus how best to target members in recruitment. This study examined how characteristics of churches and congregants’ beliefs and interests in faith-based health promotion related to their willingness to attend church-based health promotion activities. Method. We surveyed adult congregants (n = 1,204) of 11 predominately African American churches in North Carolina. Surveys collected data within four domains: demographics (age, sex, education), behavioral (church attendance, respondent food choices, and physical activity), cognitive (church-based health promotion belief, Bible-based healthy living interest, healthy living resource interest), or environmental (family health, church travel distance, church health ministry activity, church members’ food choices). Analyses used a dichotomous outcome, interest in attending programs offered by the health ministry. Domain-specific models were constructed. Logistic generalized estimating equations adjusted for clustering. Results. Of the 1,204 congregants, 72% were female, 57% were 50 years or older, 84% had a high school education or more, and 77% had a chronic health condition. In bivariate analyses and in models adjusting for all four domains, cognitive factors had the highest odds of willingness to attend. Conclusion. Congregants’ belief in the church’s role in health promotion and their desire to learn about healthy behaviors highlight the role of the African American church as a partner in addressing health disparities and the need to capitalize on this expectation through stronger partnerships between medical and faith communities.