Policy Changes and Mental Health Service Utilization in Early Psychosis

Purpose: Studies have documented how changes in mental health policies have decreased the number of inpatient beds and/or lengths of stay; and have increased focus on community services for adults with serious mental illness but with unclear effects on the utilization of these services. These studies have focused on individuals with serious mental illness later in their illness careers, usually after disability has set in. To date, there have been no reports of how these policy trends may have influenced the service utilization of persons with psychosis earlier in their illness careers, during their first episode of psychosis (FEP), a critical time during which intervention is theorized to avert or reduce future disability. Informed by Andersen's Behavioral Model of Health Services Use, we examine the mental health service utilization patterns of FEP adults in Suffolk County, New York, before and after two policy shifts in the county: the closing of a large state hospital, and the passage of legislation that diverted inpatient funds to community services.

Method: This secondary analysis draws on data from the Suffolk County Mental Health Project, an NIMH-funded prospective epidemiological study of the natural course of psychotic illness in Suffolk County, New York. From this study, 594 individuals who experienced their first hospitalization ever due to psychosis (27%, schizophrenia or schizoaffective disorder; 31%, bipolar or major depressive disorder with psychotic features; 42%, other) were assigned either to the early or late cohort group. Individuals assigned to the early cohort group entered the study between 1989 and 1992, before the 1993 closing of a state hospital in Suffolk County and the passage of the 1993 New York State Mental Health Reinvestment Act. Individuals assigned to the late cohort group entered the study after these events, between 1993-1995. Using OLS and logistic regression, inpatient and outpatient mental health service utilization in the first six months following first psychiatric admission are examined.

Results: Across both cohorts, individuals with FEP accessed an average of 32 inpatient days, seven individual therapy visits, and four medication visits. Approximately 11% accessed day treatment; less than 5% accessed any kind of family or group therapy; and less than 12% accessed any substance abuse treatment. Membership in the late cohort significantly predicted shorter length of inpatient stay after all predisposing, enabling, and need characteristics were included (beta=-16.3, p<.000). There were no differences in use of community services between the early and late cohorts with the exception of day treatment. Participants in the late cohort were more than three times (OR=3.47, p<.0001) more likely to access day treatment relative to the early cohort.

Implications: These findings demonstrate that mental health policies have altered service utilization patterns for individuals with FEP early in their illness careers. They also highlight the surprisingly low rates of utilization of community and family services as they adjust to the community following their first psychiatric admission. Research and practice efforts should more focus on this critical time for individuals who are at high risk of developing chronically disabling mental health problems.