Chinese American immigrants have one of the lowest rates of mental health services utilization among minority populations in the United States. With regard to depression, this disparity is associated with stigma, insufficient knowledge of depression and its treatment, help seeking in medical and community settings, and misdiagnosis. From the viewpoint that the manifestation of depression varies culturally, this research, composed of three studies, used an emic approach combined with item response analysis to explore cultural interpretations and expressions of distress, and their influence on assessment.

The first study investigated manifestations of social self-construal in the illness narratives of eleven men and nine women diagnosed with major depression. These narratives revealed a range of emotional, cognitive, and behavioral experiences that contained a social interpretation of the self. Also, psychological concepts of anxiety, irritability, and emotional control referred directly to a social self. This study demonstrated the social content in lived experiences of illness.

The second study examined the structure of depression. Depressed outpatients (n = 103) and community members (n = 124) completed a 47-item pilot scale containing Western and culture specific symptoms and a 21-item checklist of somatic symptoms. A multidimensional item response model of 59 items in three dimensions--psychological, somatic, and social--provided optimal fit of the data. Various patterns of dimensional expression within and across levels of overall distress were observed. Also, analysis of differential item functioning (DIF) showed significant influences of gender, age, education and acculturation on different areas of content. This study implicated a dimensional construct in illness presentation and progression.

The third study developed a self-report measure for screening in primary care and community settings. Based on responses to the 47-item pilot scale, 42 items fit a unidimensional polytomous item response model. Analysis of DIF by gender, age, and acculturation variables revealed non-equivalent items. A 9-item instrument was composed of items unbiased by gender and with content validity for the purpose of screening. This measure showed excellent reliability coefficients, and similar predictive validity but higher convergent and content validity than a commonly used Western measure. This study highlighted a role for culturally sensitive content for effective outreach and assessment.

Mental health is an integral part of health and well-being. Mental health enables people to realize their potential, cope with the stressors of everyday life, and make contributions to society. Mental, neurological and substance use (MNS) disorders constitute 13% of the global burden of disease. And yet, across all countries, public investment in preventing and treating this cluster of disorders is disproportionately low relative to this disease burden. Health systems have not adequately or sufficiently responded to the burden of MNS disorders: the gap between the need and supply of treatment ranges from 76% to 85% in low- and middle-income countries, and from 35% to 50% in high-income countries. Mounting evidence underlines the inequitable distribution, poor quality, and inefficient use of scarce resources to address mental health needs. Globally, annual spending on mental health is less than US $2 per person in high-income countries and less than US $0.25 per person in low-income countries, with 67% of these financial resources allocated to stand-alone mental hospitals. Flagrant abuse of human rights and discrimination against people with mental disorders and psychosocial disabilities have been found in such psychiatric institutions. The redirecting of mental health budgets toward community-based services, including the integration of mental health into general health care settings, is needed. To address this state of affairs, this dissertation takes a fresh look at the actions taken to formulate a comprehensive, coordinated response from health and social sectors. It is founded at the nexus of new institutional, world culture, and diffusion of innovation theories.

This dissertation employs a mixed methods approach, combining statistical and survey analyses. A mental health policy is an official statement of a government that defines its vision, values, principles, and objectives to improve the mental health of a population. It also outlines the areas of actions, strategies, timeframes, budgets, targets and indicators used to realize the vision and achieve the objectives of the policy. In the first study, I examine the coercive and emulative isomorphic effects on the diffusion of mental health policy across geopolitical borders. Using discrete-time data for 193 countries covering the period from 1950 to 2011, I conduct an event history analysis to examine the influence of WHO accession, foreign aid, and peer influence on mental health policy adoption. The results confirm that the act of adopting mental health policy is partly owed to membership in the World Health Organization, as well as influence of neighbors in the same World Bank and World Health Organization regions.

National mental health policy adoption is trumpeted as a milestone for mental health reform. Is mental health policy limited to a rhetorical plane or taken up for pragmatic reasons? The effectiveness of this "upstream" factor could be realized based on examining "downstream" models of deinstitutionalized programming. While mental health policy adoption is treated as an outcome of interest in the first study, it is treated as a predictor in the second study. More specifically, I test the phase of policy adoption as a determinant of psychiatric bed rate changes using panel data for the same 193 countries between 2001 and 2011. The analysis finds that late-adopters of mental health policy are more likely to reduce psychiatric beds in mental hospitals and other biomedical settings than innovators, whereas they are less likely than non-adopters to reduce psychiatric beds in general hospitals.

Deinstitutionalization is a much more complex and sophisticated process than reducing dehospitalization, or the reduction of psychiatric beds. It is also about improving the quality of care provided by inpatient facilities while increasing access to care through the development of mental health services in other medical and community settings. However, progress towards mental health reform is often stalled because it is an essentially contested issue in professional and advocacy circles and a highly politicized one among governments. For these reasons, the third study gathers contemporary perspectives on deinstitutionalization from 78 mental health experts. The survey administered assesses their knowledge, attitude, and practices of expanding community-based mental health services and/or downsizing institution-based care. The respondents also attested to the enabling, reinforcing, and constraining factors prevalent in the 42 countries they collectively represent. The qualitative evidence is complementary to the quantitative evidence in that it portrays the contemporary mental health system as being controlled by a nucleus of inpatient care. It further suggests that innovations are made in linking specialty services with primary and social services to support people with mental, neurological, and substance use disorders and their families as they (re)integrate into their communities.

Mental health care has branched out in new directions at the turn of the 21st century. Time and again when governments are in the throes of strengthening their mental health systems, a closer look into the setup of infrastructure, essential medicines, human resources, and civil society involvement becomes necessary. This dissertation demonstrates that deinstitutionalization is a result of mental health policies imposed from the top down by the government. The experience with deinstitutionalizing mental health care also involves grassroots mobilization of social change by citizens, clients, families, and other advocates. In parallel with service reorganization, advances have been made in training lay personnel to offer services to people with MNS disorders. Research and development have made treatment more cost-effective and accessible. Cutting across temporal and geographic borders, tradition and modernity, this dissertation probes into the permeability of mental health policy and unpacks the complexity of deinstitutionalization.

Abstract

The Effect of Placement Change on Foster Children's Utilization of Emergency Mental Health Services

by

Kya Grace Fawley-King

Doctor of Philosophy in Social Welfare

University of California, Berkeley

Professor Lonnie Snowden, Chair

Placement instability is a significant problem within the foster care system. For children who have already been removed from the care of their biological parents, additional caregiver changes can have negative effects. There is evidence that foster children who change placements frequently are more likely than their peers to suffer from emotional and behavioral problems. While researchers have found that children who change placements have an increased likelihood of using outpatient mental health services, little is known about the relationship between placement change and use of crisis or inpatient psychiatric services.

The aim of the present study was to examine the effects of placement change during the first 90 days in foster care on utilization of crisis services and inpatient psychiatric treatment among a sample of 37,699 Californian children and youth who started a new foster care spell between October 1998 and March 2001. The results suggest that the relationship between placement change and use of crisis and inpatient psychiatric services is bi-directional and is dependent on the type of placement change. These findings suggest that foster children with psychiatric problems may be more likely to have certain types of placement changes, and that these changes can be detrimental for their mental health.

This study examines policy effectiveness, system-level efficiency, and system-level equity after the devolution, or "Realignment," of California's public mental health system in 1991. There were three primary stated goals of this 1991 Realignment. First, program responsibilities for the public mental health system were shifted from the State to the counties. Second, counties were provided a dedicated revenue stream for these services from the State instead of the previous model, in which they had relied on varying amounts of annual appropriations from the Legislature. Third, counties were given financial incentives to contain or decrease spending on institutional care and granted increased flexibility to address local mental health needs within a more community-based framework. A fourth and arguably secondary goal was to address equity differences between public mental health systems by providing financing supplements to counties with a greater need, based on population and poverty measures. The first and second goals of transferring program responsibilities and providing a dedicated stream of funding to counties were relatively quickly achieved with the 1991 Realignment. This study focuses on the child, youth, and young adult Medi-Cal (California's Medicaid program) population to analyze whether the third and fourth goals of having a more community-based and equitable public mental health system were realized.

A mixed methods research design is used to evaluate whether the legislative intent for a greater focus on community-based care was met in California, and the extent to which it was achieved in different counties. The quantitative portion of the analysis focuses on changes over time in public mental health service delivery and expenditures. In the statistical analysis, 11 years of Medi-Cal claims data from fiscal year 1993-94 to fiscal year 2003-04 are analyzed for all full-scope 0-25 year old beneficiaries who received specialty mental health services. Preliminary data findings were shared with historical and administrative key informants during in-depth interviews to gain qualitative insight into data trends and regression analyses. Key informants also commented on the precursors of Realignment, both the intended and unintended consequences of Realignment, and the generalizability of the Realignment experience beyond public mental health systems and in other states.

One of the major findings is that, overall, counties were able to effectively achieve one of the primary goals of Realignment - to have their public mental health systems more focused on community-based care. Budgetary flexibility and security as well as financial incentives provided the environment necessary for counties to increase the efficiency with which they manage public mental health systems.

Although the improvement of the system's equity was not a primary goal of Realignment, the lack of emphasis on equity allowed for the continuation of disparities: those counties with low funding for their public mental health system continued to have lower funding than those counties with historically higher spending levels per beneficiary. These disparities are most noticeable in counties with larger racial/ethnic minority populations when they also have low spending levels per beneficiary. As these counties were already dedicating the vast majority of their total expenditures to community-based care, the incentives to shift to a more community-based system did not affect their service allocation trends. Furthermore, because their ability to increase their funding for the public mental health system was not enhanced, disparities persisted. Thus, financial resources play an important role for communities with larger racial/ethnic minority populations. This un-addressed inequity in the system is another important finding.

As suggested by this study and others concerning devolution and social services, although realignment policies can be effectively implemented and can show good performance in addressing efficiency in the system, future efforts that place more attention on system-level disparities will be better suited to increase equity in the system. In the case of the public mental health system, a greater focus on racial/ethnic minority populations and transition-age youth in the Mental Health Services Act of 2004 might help to address disparities for the child, youth, and young adult populations studied here. As of 2006, cultural competence reports have to be submitted [California Code of Regulations 2006] by each county. However, these efforts could be compromised if differences are not addressed as further services benefitting this population have recently been devolved to county-based public mental health systems - Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), mental health managed care, and Assembly Bill (AB) 3632 services. Thus, oversight of these issues and future studies concerning policy effectiveness, system-level efficiency, and system-level equity are warranted for this population and others following devolution.

This dissertation examines the children’s public mental health Full Service Partnership (FSP) program established by the California’s Mental Health Services Act of 2004 in order to provide mental health and social services and supports not otherwise available to the underserved. Utilizing a California statewide dataset of all public county mental health system provisions linked from two sources of data, including FSP program exposure data (Data Collection and Report dataset) and mental health service data (Client Services Information dataset) from the California Department of Health Care Services (CDHCS), analyses compare the FSP program to usual care within county mental health systems. Synthesizing records summarizing each month a child was served, the final dataset encompasses 36 counties (61%) inclusive of 623,031 (70%) children (ages 6<18) served within county mental health systems over 102 months between July 1, 2004 and December 31, 2012, reflecting 15,723 children served by the FSP program. To evaluate whether the FSP program was meeting its goals as established in statute and guidelines, three research questions were addressed: 1) Do FSP programs reach underserved children, as intended? 2) Do FSP programs provide a different array of services as compared to usual care, as intended? 3) Does participation in the FSP program result in positive outcomes as intended, measured by a decrease in the use of mental health emergency service? Adjusting for demographics, indicators of clinical severity, and county of residence, three respective analytical models were developed to compare FSP served children to those in usual care including: 1) hierarchical logistic regression modeling for the odds of a child enrolling into an FSP versus remaining in the pool of those served by usual care in each county, 2) t-tests contrasting service provision arrays for FSP served children as compared to those in intensive (service on >= four days per month) usual care, and 3) longitudinal hierarchical Poisson regression modeling the pre-post matched change in incidence rate of mental health emergency services use before, after and without FSP enrollment.

As intended by policy, results indicate that FSPs reach the underserved, provide a different array of service intensity and result in reductions of crisis care for the children and families it served. Compared to others concomitantly served in usual care, FSP enrollees had more clinical indicators of severe disorder and had encountered the mental health system at younger ages (OR=.94, P<.001), but had received fewer total lifetime months of services before enrolling into FSP (OR=.99, P<.001), especially in the six months before beginning an FSP program (OR=.19, P<.001). FSP served children also received an array of services generally more intensive than usual care, even when considering only those children served at least four days per month in usual care. The comparison of service types suggested that the FSP program followed policy guidelines which direct FSPs to offer a heightened focus on linkages to community resources (+80%, P<.001) and to support needs of caregivers and other family members (+60%, P<.001). Improved outcomes were evidenced by changes in emergency service use rates for FSP served children, given that before enrolling in the FSP program, these children showed increasing rates of mental health emergency service use over time which were then reduced or reversed after enrolling in FSP programming and throughout the remainder of the study period – a pattern unlike what was experienced by similar children in usual care. After enrollment, the older groups of FSP served children showed significant improvement in contrast to their mental health emergency service use rates before treatment and to rates of all other comparable children in usual care (ages 11<15 IRR=.83 , P<.001; and 15<18 IRR=.79, P<.001).

FSPs are customized programs which address, at least in part, two significant challenges in children’s mental health: (1) outreach and engagement of underserved populations and (2) provision of community-based stabilizing care for children at high risk for psychiatric crises. There is evidence that FSP programs might have benefits for children by (a) more effectively enrolling into care some of the 2/3 of the population with need who are unserved or underserved; (b) providing an intensive array of services inclusive of family care and linkages to external resources; and (c) resulting in improved crisis-related outcomes for children and families. FSP programs incorporate a variety of innovate components, any of which could contribute to increased success in identifying, enrolling and engaging underserved children; improving the availability of an appropriate intensity of services; or delivering positive outcomes across a lasting developmental trajectory.

Left unserved and underserved, children with severe mental disorders and their families may lack the appropriate tools to manage or improve symptoms of the disorder leading toward a progression into mental illness in adulthood. A key aspect of FSP programs is their ability to provide a combination of social and mental health services, likely helping underserved families living in poverty to overcome prior barriers to treatment. Supported by the existing infrastructure built around the FSP program, research in California is poised to make a significant contribution toward evidencing methods which increase successful treatment of undertreated children’s mental disorders potentially altering their progression. Results from this dissertation provide justification for putting effort forth toward further evaluation to identify the FSP program components which result in these program successes.