Differential labeling of mental illness by social status: a new look at an old problem

Whether the higher rates of mental hospitalization and involuntary treatment for marginal social groups are due to differential labeling or simply to the occurrence of higher rates of disorder in these groups remains unresolved. I reexamine this issue with data from the National Comorbidity Survey (N = 5,877) that allow comparisons between disturbed individuals living in the community untreated and disturbed persons who have been hospitalized or seen a professional for their mental health problems under pressure or voluntarily. Contrary to labeling theory, members of lower status groups are not consistently overrepresented among those who have been hospitalized or seen a professional against their will. Consistent with self-labeling theory, persons with greater education and those not in poverty are disproportionately present among individuals who sought treatment by choice. Additional analyses show that factors that predict service utilization are important determinants of mental health service use but do not account systematically for status disparities in hospital or outpatient treatment, especially disparities by poverty status. Although I do not confirm a central tenet of labeling theory here, the negative consequences of labeling and stigma continue to be well-supported in the literature.     

The career of the mentally ill: an integration of psychiatric, labeling/social construction, and lay perspectives

This paper provides a new way of conceptualizing the career of the mentally ill. Most persons who experience an episode of a serious mental disturbance lead a normal life, while a few persons lead lifetimes that revolve around their mental disorders. The processes leading to either result can only be understood by integrating the traditional labeling and psychiatric perspectives with lay understandings of the concepts of "mental illness" and "nervous breakdowns." A selection of key concepts from these perspectives leads to a better understanding of the different paths persons take as they move through the pre-patient, inpatient, and post-patient phases of the "career of the mentally ill." This perspective makes understandable a number of counterintuitive relationships. For example, it explains why most hospitalized mental patients (1) have a negative stereotype of the "mentally ill," (2) do not perceive themselves as "mentally ill, yet (3) perceive themselves as benefiting from treatment, and (4) do not progress into a career of secondary deviance.     

Psychiatric nursing in the 1990s & beyond.

In the decade of the '90s, psychiatric mental health nursing will need to take stock of itself--its practice, its education, and its research--if it is to successfully prepare for the changes in care of the mentally ill. Like psychiatrists, we will need to rethink our agendas in light of new science and technology and rationalize the mental health delivery system and our role in it through systematic research and advocate for a system that provides quality care for the chronically ill and the poor. In the next century, we will need to rethink the basics of nursing care and the leadership roles of nurses as hospitals and the doctor's role within them changes. Psychiatric mental health nurses will need to be at the forefront in advocating for a delivery system that listens to patients and families, that humanizes the dehumanizing experience of hospitalization. The challenges before us are formidable.     

CAN A HIGH SENSE OF CONTROL AND JOHN HENRYISM BE BAD FOR MENTAL HEALTH?

Social stratification profoundly affects mental health. Specifically, substantial empirical evidence finds that higher status promotes mental health via a higher sense of control and a propensity to cope actively with problems. An unresolved issue, though, is whether the effects of sense of control and active coping on mental health are uniformly beneficial across levels of socioeconomic status. Perceived control and John Henryism, an active coping style, may undermine mental health, especially for lower-status persons, who lack resources. Using data from the National Comorbidity Survey for African Americans, Hispanics, and whites, we find that both sense of control and John Henryism tend to be monotonically related to positive mental health regardless of socioeconomic status and race/ethnicity.     

Effects of Medicaid managed care policies on mental health service use among a national probability sample of children in the child welfare system

Children in the child welfare system are dependent upon Medicaid to finance services for their considerable mental health needs. This study examines the effects of Medicaid policies on mental health service use among a national probability sample of children in the child welfare system. Data for this study came from the National Survey of Child and Adolescent Well-Being, the Caring for Children in Child Welfare study, and the Area Resource File. Weighted multivariate logistic regression analyses were conducted to estimate effects of policy variables on children's use of mental health services, controlling for child-level covariates and county-level health resources. Children in counties with behavioral carve-outs under Medicaid managed care had lower odds of inpatient mental health service use. Medicaid managed care enrollment and variations in type of provider reimbursement did not affect use of mental health services. Older age, greater need for mental health services, and higher levels of caregiver education were associated with increased odds of service use. Restrictions on use of inpatient mental healthcare caused by behavioral carve-outs may disproportionately affect children in the child welfare system who have high rates of such use. Careful adoption of carve-outs is necessary to assure appropriate care for these children.     

Meeting the Needs of the Mentally Ill Homeless in Massachusetts-Based Emergency Shelters

A statewide survey (response rate = 79.5%) of the emergency shelters designed for homeless individuals was conducted in Massachusetts to determine the prevalence of serious mental illness among residents and extent to which they received psychiatric services. An average prevalence rate of 22%, ranging from 1% to 70%, was reported despite the fact that 87% of the shelters restricted admission of those exhibiting severe behavioral problems. Nearly three-quarters of the shelters reported providing some mental health services as part of their program, and 80% had established ties with professional mental health agencies. Linkages with these mental health agencies greatly enhanced placement options for mentally ill persons. When queried on the most pressing community-based service needed for the homeless mentally ill, nearly two-thirds of the shelters reported a need for additional housing alternatives.     

The need for policy direction in the provision of care to the mentally ill: an interdisciplinary view

This paper argues that mental health care is underprovided, and that the role of nonprofit providers should be expanded for three major reasons. First, a positive externality exists since society, as a whole, benefits when those in need of mental health care consume care. External benefits include lower crime rates, lower unemployment, and less homelessness. Second, consumers of mental health care are mentally ill and often do not believe that they need care, underestimate their need, or believe that care is not worth the time or expense. Third, common law, to a large extent, is based on individual liberty, largely ignoring the benefits individuals receive from treatment. It is argued that government policy is needed to increase the supply of mental health care, through nonprofit agencies.     

Promoting public/academic linkage.

1. Collaborative linkages between public mental health/mental retardation service systems and academic institutions have evolved in response to several problems: increasing numbers of individuals requiring long-term mental health care; the nursing shortage; and a decline in enrollment and students graduating from psychiatric mental health nursing programs. 2. Evidence suggests that a public/academic linkage in the form of a multidisciplinary training course in the care of seriously mentally ill patients promotes a recruitment of mental health professionals to work with these patients. 3. The establishment of academic/health care system linkages can enhance client care, expand and improve clinical experiences and education for students, and provide opportunities for collaborative research among clinical staff, faculty members, and graduate students.     

Managed care. The effect of case management on state psychiatric clients.

This study examined whether case management services, mandated under the managed care contract for adult clients in a medium-sized state psychiatric hospital in Tennessee between July 1996 and June 1997, were offered as specified, and the impact these services had on recidivism for individuals who were identified as having a severe or persistent mental illness. Although all of the clients were offered case management, 47% refused the service. Of the 14 who had one or more readmissions, six (43%) had case management. These findings demonstrate that health care providers must offer sufficient information to their clients so that they can use the managed care system more effectively.     

No Longer Intending: The Relationship Between Relinquished Fertility Intentions and Distress

We use data from both waves of the National Survey of Families and Households to assess whether relinquishing a serious intention to have (more) children leads to greater increases in depressive symptoms than continuing confidence in childbearing intentions. Our sample includes 2,200 individuals of childbearing age, men and women, all parities, and all marital statuses. Change score analysis shows that individuals who relinquished a serious intent to have children had elevated distress at Time 2 and that the association is conditioned by gender, health, and education. We find that fertility potential can be important to psychosocial well‐being and that closing the door on future fertility, especially for women, those in ill health, and the better educated, leads to increased distress.     

Joint commission evaluation of behavioral health care organizations

The joint Commission on Accreditation of Healthcare Organizations has accredited behavioral health care organizations since 1957. Accredited behavioral health care organizations include organizations providing services to persons with psychiatric disorders, substance abuse disorders, or developmental disabilities/mental retardation; or, provide social services to other related populations. In the late 1980s, the Joint Commission initiated the redesign of accreditation to include performance measurement. Performance measurement initiatives include the IMSystem, Requests for Indicators, National Library of Healthcare Indicators, and a national Council on Performance Measurement. These initiatives are steps toward the integration of performance measurement data into the accreditation process.     

The Well‐Being of Children Born to Teen Mothers

Children born to early child bearers are more likely than other children to display problem behaviors or poor academic performance, but it is unclear whether early childbearing plays a causal role in these outcomes. Using multiple techniques to control for background factors, we analyze 2,908 young children and 1,736 adolescents and young adults in the National Longitudinal Survey of Youth (NLSY79) and the NLSY79 Children and Young Adults (CNLSY79) data sets to examine whether early childbearing causes children’s outcomes. We find evidence that teen childbearing plays no causal role in children’s test scores and in some behavioral outcomes of adolescents. For other behavioral outcomes, we find that different methodologies produce differing results. We thus suggest caution in drawing conclusions about early parenthood’s overarching effect.     

Rethinking a universal framework in the psychiatric symptom-disorder relationship

Research on disparities in health and services should include a critical examination of how social, cultural, and contextual factors affect the connection between symptoms and psychiatric disorders. Systematic differences in this connection by these factors will mean that clinicians using a universalist approach to disorders may make more diagnostic errors for certain patients (e.g., ethnic minorities, the poor). Based on the literature on normative clinical decision-making, this study tests for whether the effect of specific psychiatric disorders on key symptoms is the same for certain groups of the population. The data come from the National Comorbidity Survey. Conditional probabilities of disorders and symptoms, the elements feeding into clinical decision-making, are calculated and tested for equivalence across various racial/ethnic, educational, income, and gender groups. We find some significant differences in the relation of key symptoms to disorders across groups. These findings should encourage testing relativistic frameworks in diagnostic nosology as a step to improve clinical decision-making and reduce diagnostic and treatment disparities in mental health services.     

Open Adoption and Post-Adoption Birth Family Contact: A Comparison of Non-Relative Foster and Private Adoptions

This study used data from the National Survey of Adoptive Parents (NSAP) to compare post-adoption contact in families with non-relative private domestic and foster care adoptions. This study is the first to use a nationally representative sample to examine and compare the extent of post-adoption contact in both private and foster adoptions. The results suggest that children adopted from foster care were less likely to experience post-adoption contact with their birth families than children adopted privately despite the fact that they were more likely to have lived with their birth families.     

Issues in mental health care benefits: the costs of mental health parity

This Issue Brief discusses issues in mental health care benefits. It describes the current state of employment-based mental health benefits and discusses studies and issues regarding full mental health parity. It also includes an analysis of the effect of full mental parity on the uninsured population and the effects of the limited mental health parity provision contained in the VA-HUD appropriations bill. The final section discusses the implications of mental health parity for health plans and health insurers. When employers began to provide health insurance benefits to their employees and their families, they extended coverage to include mental health benefits under the same terms as other health care services. Many employers continued to add mental health benefits through the 1970s and early 1980s until cost pressures required employers to re-examine all health care benefits that were offered. They quickly found that, while only a small proportion of the beneficiaries used mental health care services, the costs associated with this care were very high. As a result, employers placed limits on mental health benefits in an attempt to make the insurance risk more manageable. The general strategies employers have used to manage their health care costs are cost sharing, utilization review, managed care, and the packaging of provider services. Employers' cost management strategies may be restricted, however. Five states have mental health parity laws, but three of the states--Rhode Island, Maine, and New Hampshire--apply these laws only to the seriously mentally ill. In addition, 31 states mandate that mental health benefits be provided. However, state mandates apply only to insured plans, not to self-insured employer plans, which are exempt from state regulation of health plans under the Employee Retirement Income Security Act of 1974 (ERISA). A number of recent studies have examined the effect of mental health parity on health insurance premiums in a "typical" preferred provider organization and on the uninsured. In general, the studies concluded that mental health parity could increase health insurance premiums, decrease health insurance coverage for non-mental health related illnesses, and increase the number of uninsured individuals. All studies of mental health parity, and mandated benefits in general, assume that there is a strong likelihood that increased health benefit costs would be passed along to workers in the form of higher cost sharing for health insurance, lower wage growth, or lower growth in other employee benefits.     

Economic antecedents of mental hospitalization: a nineteenth-century time-series test

More than 100 studies have cited M. Harvey Brenner's (1973) claim that fluctuations in the economy increase the onset of mental illness and thus generate increases in mental hospitalization. Published attempts to replicate Brenner, however, have considered only twentieth-century data. One of Brenner's most memorable claims was that a stable inverse relationship between mental illness and the economy could be seen over a 127-year span beginning in the early nineteenth century. Unfortunately, no research since Brenner's has considered nineteenth-century populations. In this paper we analyze the hypothesis that economic change provokes a substantial fraction of first admissions to mental hospitals. We used admissions registers from the three institutions to construct a data base that approximates a psychiatric case register for a nineteenth-century American city from 1881 to 1891. Time-series tests show no support for the "provocation" hypothesis.     

The history, economics, and financing of mental health care. Part 3: The present

1. Health care system changes, particularly the managed care plans, are altering mental health practices in significant ways. The autonomy and independent judgment of clinicians are being limited. 2. Market expansion created child and adolescent hospitals in the private sector. This market was very favorable to growth because of the great ambiguity in diagnosis and treatment, and the nonexistence of commitment laws for this population. 3. While insurance coverage for psychiatric diagnoses has expanded, more affluent people, with good employment possibilities, still have better insurance than poor individuals.     

A psychiatric nurse's role

1. Homelessness in America is a result of complex social, political, and economic forces; approximately one third to one half of the homeless have severe emotional problems. 2. The person with chronic mental illness who is also homeless will face numerous obstacles when the need for psychiatric care arises. 2. The person with chronic mental illness who is also homeless will face numerous obstacles when the need for psychiatric care arises. 3. The federal government is beginning to address the problems of the homeless chronically mentally ill population by establishing pilot programs in Veterans Administration hospitals. 4. The psychiatric nurse is in a unique position to provide services to those who are homeless and mentally ill.     

How Early Life Religious Exposure Relates to the Timing of First Birth

This article examines intermediary processes explaining how religious socialization and involvement early in life are related to the timing of first births for women in the United States. The theory of conjunctural action forms the basis for hypotheses for how religious schemas and materials operate to influence birth timing. Using the National Longitudinal Survey of Youth data and event history methods, the study finds evidence for expected family size, work–family gender ideology, educational attainment and enrollment, cohabitation, and age at marriage as mediators of associations between early life religious exposure (affiliation and attendance) and the timing of nonmaritally and maritally conceived first births. These findings corroborate other research identifying the long reach of religious socialization and involvement in youth, elucidate some of the pathways for these connections, and motivate further work to understand linkages between religion and family behaviors in the United States.     

Divorce and Adult Psychological Well‐Being: Clarifying the Role of Gender and Child Age

Substantial evidence indicates that marital dissolution has negative consequences for adult well‐being. Because most research focuses on the average consequences of divorce, we know very little about factors that moderate this association. The present study tests the hypothesis that the effects of marital dissolution on adult well‐being are greatest for those with young children in the home at the time of marital dissolution. Analysis of data from the National Survey of Families and Households (N= 4,811 men and women married at the baseline interview) supports this hypothesis, especially among women. For women without young children, marital dissolution appears to have few negative consequences for psychological well‐being. Differential exposure to secondary stressors that accompany marital dissolution partly explains these patterns.