been studied despite high rates of mental disorder in ... ziner and Thomas Permutt are with the School ..... New Canaan, Conn: Mark Powley Asso- ciates; 1983.
Mental Health Service Use by the Elderly in Nursing Homes
IL
Barbara J. Bums, PhD, H. Ryan Wagner, PhD, John E. Taube, MLS, Jay Magaziner, PhD, Thomas Pennutt, PhD, and L. Richard Landerman,
Introduction A mandate to treat mental illness in nursing home residents is expressed in Public Law 100-203, also called the 1987 Omnibus Budget Reconciliation Act. ' Under the provisions of this law, nursing homes are required to screen both applicants for admission and current residents for mental disorders.2 Residents who need " active treatment" are to be identified and treated in the nursing home or else discharged to an appropriate psychiatric treatment facility. Estimates of the impact of the law have been developed for the cost of screening, the number of residents likely to be moved to other settings,3 and probable violations of neuroleptic prescribing regulations.4 However, national data on the availability and use of mental health services by nursing home residents-including the predictors of such use-have not yet been examined for the United States. The 1985 National Nursing Home Survey offers a way to probe the availability of mental health services to nursing home residents before the budget reconciliation act was implemented. Because it collected data on medical (including psychiatric) conditions and services received, the survey can function as a source of baseline information on mental health treatment. Treatment of mental illness among elderly nursing home residents has seldom been studied despite high rates of mental disorder in this population.- The 1985 survey reports the rate of mental illness among these patients to be 64%,9 somewhat lower than the 81% rate obtained when patients were assessed with a research diagnostic interview.1(0 Certain mental disordersparticularly depression-have been associated with increased mortality in nursing
P/iD
home patients. " But although the need for treatment is clear and there is evidence of effective psychosocial interventions for older persons,12-'l the available literature points to minimal contact between these patients and mental health professionals.'6 The most likely treatment, if any, is psychotropic medication, which is often prescribed inappropriately by general practitioners. 17-2"' Useful treatments for older persons include psychosocial interventions as well as the selective prescription of psychotropic medications that takes into account special issues in prescribing such drugs for older persons.2' '2 This paper is intended to provide baseline data on mental health treatment in nursing homes prior to the Omnibus Budget Reconciliation Act. The aims of the study are to (1) determine rates of use of mental health service (e.g., evaluation or treatment) provided by either a mental health professional or a nonpsychiatric physician to elderly nursing home residents, and (2) identify patient and service system factors that predict mental health service use. The lack of large-scale mental Barbara J. Bums, H. Ryan Wagner, and L. Richard Landerman are with the Department of Psychiatry at Duke University Medical Center in Durham, NC. John E. Taube is with the College of Library and Information Services, University of Maryland, College Park. Jay Magaziner and Thomas Permutt are with the School of Medicine at the University of Maryland in Baltimore. Requests for reprints should be sent to Barbara J. Bums, PhD, Professor of Medical Psychology, Box 3454, Department of Psychiatry, Duke University Medical Center, Durham, NC 27710. This paper was submitted to the Journal December 2, 1991, and accepted with revisions March 17, 1992. Editor's Note. See related commentary by Fogel (p 319) in this issue.
American Journal of Public Health 331
Bus et al.
health services research on this population means that this study is basically exploratory; however, its analytical prototype can be found in the Andersen model23 (which examines the effects of predisposing, enabling, and need factors) and in research on service system variables such as resources and reimbursement.24,25
Metods Survey Design Data for this paper are drawn from the 1985 National Nursing Home Survey, the sixth in a series of surveys conducted periodically by the National Center for Health Statistics and designed to provide comprehensive information about nursing homes, residents, and the use oflong-term care services. Conducted between August 1985 and January 1986, the survey covered a nationwide (excluding Alaska and Hawaii) sample of nursing and related care homes, their residents, discharges, and staff. The survey was based on a probability sample of facilities that have three or more beds and are equipped and staffed to provide routine nursing and personal care services to residents. The sample frame of 20 479 homes included all types of nursing homes without regard to level of care, Medicare/Medicaid participation, or licensing. Of the 1220 institutions selected from this frame, 1079 participated in the survey. A facility could be freestanding or a nursing care unit of a hospital, retirement center, or similar institution, provided that separate financial and employee records were being maintained. Board-and-care and residential care homes were excluded. The sample was selected according to a two-stage probability design. Facilities were selected in the first stage. The universe consisted of one base and three supplementary components: (1) the 1982 National Master Facility Inventory-a census of nursing and related-care homes, (2) the 1982 Complement Survey of the National Master Facility Inventoryhomes identified as "missing" from the 1982 inventory, (3) hospital-based nursing care units listed by the Health Care Financing Administration, and (4) establishments opened for business between 1982 and June 1, 1984. Two strata were defined within the universe: facilities certified by either Medicare or Medicaid, and facilities certified by neither. The entire universe was ordered by ownership, geographic region, metropolitan status, state, county, 332 American Journal of Public Health
metropolitan statistical area, and zip code. The facility sample was then selected systematically after a random start within each primary stratum. Residents, discharges, and staff registered nurses were selected in the second stage. Five or fewer residents per home were selected from entries on the current resident sampling list. The current resident questionnaire was administered to the nursing staff person who was most familiar with the selected resident's care; the medical record was also used as a source of information. The facility questionnaire was administered to nursing home administrators. Response rates differed, with a 100% rate for the facility questionnaire and a 97% rate for the current resident questionnaire. Further details about the survey procedures, sample frame, and design appear in published reportS.26,27 Data used in this study are from both questionnaires. Subjects are nursing home residents aged 65 and over (n = 4646). This unweighted sample represents the population of 1 318 300 elderly US nursing home residents.9 Weighted data were analyzed, although the tables show actual sample size.
Statistical Methods Providers of mental health treatment may be mental health specialists or general practitioners. In a study of community residents, Leaf and colleagues report that different predictors of treatment are associated with different types of service providers.28 They also argue that failing to analyze treatment separately for the general medical sector and the mental health specialty sector can confound and obscure effects specific to each sector. Accordingly, in this study of elderly nursing home residents, the analyses model general medical treatment and specialty mental health treatment separately. Within each sector, factors are examined that differentiate the type of health professional providing the service. Specifically, three dichotomous outcome variables were contrasted: (1) treatment by mental health specialists vs no treatment (n = 4546); (2) treatment by
nonpsychiatric physicians vs no treatment (n = 4537); and (3) type of health professional providing treatment-that is, mental health specialist (n = 109) vs general physician (n = 100)-among those who received treatment. The dependent variable-use of mental health services provided by any type of mental health professional-comes from the current res-
ident questionnaire, which inquires about evaluation or mental health treatment received within the past month. Neither the type, quantity, nor quality of care provided was specified. Health professionals were differentiated as psychiatrist, psychologist, psychiatric social worker, psychiatric nurse, and physician other than a psychiatrist. The first four groups were combined into one group (mental health specialist) because of small sample sizes in these categories. Independent variables were grouped into four general categories. Group I included three exogenous variables: age, race, and sex. Group II measured the following nursing home characteristics: type of home ownership (nonproprietary or proprietary), number of beds, location (nonmetropolitan or metropolitan), region (Northeast, North Central, South, or West), and the percentage of patients reimbursed by Medicaid (less than 25%, 25% to 49%, 50% to 74%, and 75% or more). The remaining groups measured two dimensions of resident characteristics. Group III variables included marital status, the number of dependencies in activities of daily living, source of payment (Medicaid or non-Medicaid), and length of residence (less than 30 months or 30 months or more). Group IV clustered psychiatric need variables: (1) residence prior to entering a nursing home (hospital, psychiatric hospital, or other), (2) current psychiatric diagnosis (dementia, including Alzheimer's disease; schizophrenia/ psychosis; other mental disorder diagnoses; or no diagnosis), and (3) two symptom indices: exhibition of aggressive behavior or mood disturbances. Diagnosis was obtained from a checklist of mental disorders in the current resident questionnaire. Because of multiple conditions, study subjects were assigned to diagnostic categories on a hierarchical basis. In rank order, these categories are dementia (including all organic brain syndromes), schizophrenia/psychosis, and other mental disorders (primarily anxiety, depression, and personality disorders). (For detailed data on specific conditions from the checklist and a limited number of cases assigned International Classification of Diseases codes for mental disorders, see Strahan and Burns 1991.9) Dummy variables were formed to represent nominal polychotomous predictor variables (e.g., region, marital status, and diagnosis). The population was analyzed with a complete series of mutually exclusive dichotomous outcome variables. In the first set of analyses, residents treated by menMarch 1993, Vol. 83, No. 3
Mental Health Service Use in Nursing Homes
tal health professionals were compared with untreated residents; residents seen by both a mental health specialist and a general practitioner (n = 15) were included in this group. In the second set of analyses, general practitioner treatment was compared with no treatment, excluding specialist-treated residents from the analysis. The third set of analyses compared the two types of treatment using a strategy for logistic regression with polychotomous outcomes as presented by Wijesinha et al. (1983).29 Each set of analyses proceeded through three stages. First-stage models included the three exogenous variables. These were carried forward into subsequent models to serve as control variables and to enable the analysts to ascertain whether their effects were (statistically) explained or suppressed by other predictors. At the second stage, variables describing nursing home characteristics and group III (descriptive) patient characteristics were added sequentially to the models and tested for significance. Only significant (P < .05) stage 2 predictors were retained in subsequent models. In the case of nominal polychotomous variables, all representative dummy variables (less one to avoid singularity) were added to the model concurrently; if one or more dummy coefficients were significant, all were carried forward. At the end of this second stage, an inclusive model containing all evaluated variables (regardless of significance level) was run to test for possible suppression effects. In the third stage, the procedure was repeated by sequentially analyzing psychiatric need characteristics (group IV); models at this stage included the three exogenous variables from stage 1 and any stage 2 variables that had reached significance in the prior analyses. A final analysis was done to identify variables that distinguish between types of health professionals providing mental health treatment; this third model included significant variables from the regressions of the first two models.
Results Table 1 shows rates of mental health treatment for elderly nursing home residents by type of health professional providing treatment. Slightly more than 2% of residents had contact with a mental health
professional, and a similar proportion received some mental health care from a general physician. Thus, a total of 4.5% of the elderly resident population received some mental health carefromeitherorboth health March 1993, Vol. 83, No. 3
professional types. This figure contrasts with a diagnosis of mental disorder for two thirds of the population-51% with dementia, 4% with schizophrenia/other psychosis, and 11% with other mental disorders (see Table 2). Rates (weighted) of mental health professional contact (Table 2, columns 2 and 3) range from a low of less than 1% (for older than 85 years, no mental disorder, and 25% to 49% residents on Medicaid) to a high of 17% (a diagnosis of schizophrenia/psychosis). Rates show less discrimination for mental health contact with a general physician than for contact with a mental health specialist, and they vary only slightly around the 2.2% rate for the population. The sample population distribution for each variable is shown in the left column of Table 2 to provide a perspective on the rates of mental health care in columns 2 and 3. Exponentiated logistic regression coefficients (odds ratios) appear in Table 3. The ratios represent changes in the odds of treatment relative to the omitted category (in the case of categorical variables) and multiplicative changes in the odds for each unit increase (in the case of continuous variables). The first column of Table 3 shows predictors of treatment by mental health specialists. At the first stage of analysis, using the three exogenous variables, the only significant (negative) predictor of treatment was age. At the second stage, specialist care was predicted by regional and financial characteristics of nursing homes. Nursing home residents in the north central and southern regions of the United States were less than half as likely to receive treatment by a mental health specialist as were residents in the West (the omitted category). Specialty treatment was about 25% less likely to occur in facilities where one fourth to one half of the patients were on Medicaid than in homes where fewer than one fourth of the patients were on Medicaid. Among homes with more than one half of their patients on Medicaid, a much weaker (nonsignificant) trend in the same direction was evident. Type of ownership, location in nonmetropolitan areas, and number of beds were nonsignificant (data not shown). Among variables describing patient characteristics, being married was a significant negative predictor of treatment after the effects of age, sex, and race were accounted for, but it became nonsignificant when region and proportion on Medicaid were added to the model. Length of residence (more or less than 30 months),
number of activities-of-daily-living dependencies, and mode of payment (Medicaid or otherwise) were nonsignificant predictors (data not shown). Psychiatric need characteristics of residents were important predictors of specialty treatment. Residents with dementia were almost three times more likely to receive treatment than residents without a psychiatric diagnosis (the omitted category). A diagnosis in the category of other mental disorders increased the odds of treatment almost fivefold, whereas the odds of specialty treatment were 13 times greater for persons diagnosed with schizophrenia than for residents without a psychiatric diagnosis. Prior residence in a mental hospital increased the odds of specialty treatment twofold. Not surprisingly, the latter effect was double before the diagnostic variables were added to the equation. Among symptom variables, aggressive behavior was not a significant predictor of treatment whereas mood disturbance was. Repeating the above analyses to predict mental health services provided by a nonspecialist physician produced a markedly different pattern of results (Table 3, column 2). Of the three exogenous variables, age was no longer a significant negative predictor. Among variables related to nursing home characteristics, region remained important: as with specialty treatment, location of homes in the north central United States decreased the odds of treatment relative to the (omitted) western region; location in the South showed a similar pattern although the coefficient was nonsignificant. Residence in the Northeast was a significant positive predictor of treatment. Also, the odds of treatment by a nonspecialist were significantly increased for nonproprietary nursing homes, for homes in nonmetropolitan regions, and for homes in which more than one quarter of the residents were on MedAmerican Journal of Public Health 333
Burns et a.
icaid (although significantly so only in the second and fourth quadrants). Neither marital status, activities-of-daily-living dependencies, source of payment, nor length of residence predicted significantly. (Data for the latter three categories are not shown.) The effects of resident psychiatric characteristics were substantially different for nonspecialist treatment compared with the corresponding effects for treatment by a mental health specialist. Among the variables representing current diagnosis, none was a significant predictor of care by a general physician. Mood disturbance remained nonsignificant, but the presence of aggressive behavior was a positive predictor of nonspecialist as opposed to specialist treatment, perhaps reflecting a tendency to medicate troublesome residents. The analyses described above were focused on the factors affecting treatment (vs no treatment) by a mental health specialist and by a general physician. The results in columns 1 and 2 indicate that some factors (e.g., diagnosis, aggressive behavior) were significant predictors for one but not the other type of health professional. This was explicitly tested by rerunning the analyses on the treated population alone (n = 209) to contrast factors that distinguish the health professional types. Thus, the odds ratios in column 3 indicate the odds of being treated by a mental health specialist vs a general physician. Age was a significant negative predictor of specialty service; older residents were less likely to see a mental health professional. Among variables representing service system characteristics, region, locale, and percent of Medicaid support discriminated between health professional types. Location of homes in the Northeast predicted negatively for specialist treatment relative to homes in the West. A similar tendency was apparent in homes in the north central and southern regions, although examination of columns 1 and 2 suggests that the latter two dummy variables tended to predict negatively for treatment irrespective of type of health professional. A nonmetropolitan locale and a percentage of Medicaid residents between 25% and 49% were also negative predictors of specialty treatment. Percentage of residents on Medicaid in the two highest categories (50% and 74%) showed a similar outcome but failed to reach significance, perhaps reflecting the limited power of the analysis related to the small sample size.
334 American Journal of Public Health
March 1993, Vol. 83, No. 3
Mental Health Service Use in Nursing Homes For variables related to psychiatric need characteristics of residents, evidence of mood disturbance or a diagnosis of schizophrenia were significant positive predictors of specialty treatment. Referral from a psychiatric hospital was a negative predictor of specialty services. This reflected the large increase in the odds of treatment by a general practitioner for such residents even though the odds of treatment by a specialist were more than double those for the omitted category. Dementia and the presence of an other mental diagnosis increased the odds of treatment by a mental health specialist approximately twofold although neither outcome was significant, perhaps again owing to the limited statistical power of the latter analysis.
Discussion Rates of Senice Use The first aim of this paper is to determine rates of mental health service use among elderly nursing home residents. Data presented here show that rates of contact with either a mental health professional (2.3%) or a general physician (2.2%) during the past month are extremely low relative to any estimate of current mental illness. However, several caveats are in order. Service use rates may be underestimated because of the limits of the data collected. Estimates of treated prevalence usually cover longer time periods, such as 6 months or a year rather than the 1-month span covered by the National Nursing Home Survey. The only data source for an extended time period that the authors could identify was a study of nursing homes in Delaware. During 1 year, in a study begun in 1989, 2.2% of Delaware nursing home residents had contact with a psychiatrist (S. Sherwood, Director, Department of Social Gerontological Research, Hebrew Rehabilitation Center, personal communication, 1991). In the National Nursing Home Survey, 1% of the specialist care was provided by a psychiatrist. If the Delaware estimate were applicable to the national survey, the estimate for contact with a psychiatrist would double to 2%; if the same assumption were made for the other mental health professionals and general practitioners, the maximum annual estimate of treatment could be as high as 8%. The overall low rate of specialty care is not surprising, given the research on mental health service use by older persons March 1993, Vol. 83, No. 3
in primary health care or community mental health settings.5'30 Epidemiologic Catchment Area data show that 6.2% of community residents aged 55 and older visited a specialty mental health professional within the past 6 months.31 A Baltimore study of newly admitted nursing home patients showed that only 7.5% had used community mental health resources prior to placement.32 The very low rate of general practitioner care contrasts with results of other nursing home studiesincluding the National Nursing Home Survey pretest, which pointed to a high use of psychotropic drugs prescribed by such physicians. It appears that notations of psychotropic medications were not linked to a diagnosis of psychiatric condition; this was the case in 21% of such prescriptions in the national survey pretest.19 Even if these reported treatment rates represent an underestimate of the care provided, the gap between care and estimated mental disorder (66.4% of this study is based on medical record diagnoses) indicates considerable unmet need. The actual rate of mental disorder may be
even higher. When research diagnoses were used to estimate prevalence of mental disorder among persons admitted to nursing homes in Baltimore, German et al. (1992)10 found 81% to have a diagnosable disorder, thereby widening the gap between the need for and the provision of care even further. Implications of these findings are relevant to concerns about quality of care for older nursing home residents, as defined by the Omnibus Budget Reconciliation Act. Barriers to care have been examined
by several investigators. Explanations that have been offered include (1) poor reimbursement for mental health services, (2) the limited mental health training of general medical physicians, and (3) a lack of confidence in available treatment for psychiatric disorders in older persons.33,34
Predictors of Use The second aim of this study was to examine patient characteristics and service system factors associated with receipt of mental health services to identify further what drives or inhibits the provision of American Journal of Public Health 335
Buns et aL
mental health care in the nursing home setting. Factors influencing specialist care were largely clinical characteristicsparticularly diagnosis, mood disturbance, and transfer from a psychiatric hospital. This is encouraging from the perspective that the minimal care provided may be directed toward more severely ill persons. For example, the odds of treatment with a diagnosis of schizophrenia (vs no mental diagnosis) are 13:1. Still, only one of six residents with this condition receives care, underscoring the issue of unmet need. The finding that younger patients (those aged 65 to 74 years) receive more care than older patients may indicate that this group is more difficult to manage, that there is more hope about a positive response to treatment, or that health professional preference is a factor. To pursue this finding, the relationships between age and aggressive behavior, age and diagnosis, and aggressive behavior by diagnosis were also investigated; no significant interactions were observed (data not shown). Significant system variables related to specialist care were in a negative direction. The finding that specialist care is unlikely in the north central and southern regions can be linked to more limited mental health resources in these regions.35 The finding that care is less likely in homes in the second quadrant (25% to 49%) ofMedicaid patients than in homes having the lowest proportion of Medicaid patients may indicate that homes with better insured patients are more likely to attract the services of a mental health professional. Mental health care by a general practitioner is more responsive to service system variables and is less discriminating for clinical variables (such as diagnosis, which is not significant). The Medicaid findings are reversed-that is, patients in homes in the second and fourth quadrants are four and five times more likely to get care than those in the first quadrant. The Medicaid findings for the second quadrant hold up in the odds ratios for care by a specialist vs a general practitioner, as well as for a nonmetropolitan location, contributing to a picture of the general practitioner as the mental health provider in settings characterized as more public and rural. The role of the general practitioner appears to differ from that of the mental health specialist as it places a relatively greater emphasis on managing aggressive behavior. This probably takes the form of ordering restraints or psychotropic medications as needed. In contrast, specialist intervention is more likely to focus on 336 American Journal of Public Health
mood disturbances. Contact with patients transferred from psychiatric hospitals is characteristic of both health professional groups. Overall, the receipt of mental health services by older nursing home patients occurs on a fairly random basis. Practitioner practices influence the provision of care to some extent, but the larger picture reflects a lack of resources: neither mental health professionals prepared to provide care in nursing homes nor general medical physicians trained to treat mental illness are readily available. To begin reducing the gap between diagnosis and service use, a better estimate of the need for care must first be developed; this estimate should be based on current knowledge about effective treatments for specific patients groups with mental disorder, treatments often complicated by comorbid medical conditions. Next and more critical is to circulate knowledge of effective treatment strategies and management regimens (especially for depression or anxiety comorbid with dementia, present in 45% those with dementia) that are now available.10 The current estimate of need based on elderly residents with some type of mental disorder diagnosis is 843 000 persons,9 of whom only 37 935 (4.5%) receive any mental health care from a mental health specialist or general practitioner. Considering that implementation of the Omnibus Budget Reconciliation Act will press nursing homes into awareness of the mental health needs of patients, our data demonstrate the urgency of building a mental health service delivery system that is responsive to the needs of these patients-a critical public health challenge. E
Acknowledgments The authors acknowledge G. Kay Bishop of Duke University Medical Center for technical assistance in manuscript preparation.
References 1. Omnibus Budget Reconciliation Act, Pub L No. 100-203, ยง4211 (c) (7) (1987). 2. Morris JN, Hawes C, Fries BE, et al. Designing the national resident assessment instrument for nursing homes. Gerontolo-
gist. 1990;30:293-307.
3. Freiman MP, Arons BS, Goldman HH, Bums BJ. Nursing home reform and the mentally ill. Health Aff 1990;9:47-60. 4. Garrard J, Makris L, Dunham T, et al. Evaluation of neuroleptic drug use by nursing home elderly under proposed Medicare and Medicaid regulations. JAMA. 1991;
265:463-467. 5. Bumns BJ, Taube CA. Mental health services in general medical care and in nursing
homes. In: Fogel BS, Furino A, Gottlieb GL, eds. Mental Health Policy for Older Americans: Protecting Minds at Risk Washington, DC: American Psychiatric Press; 1990:63-84. 6. Goldman HH, Feder J, Scanlon W. Chronic mental patients in nursing homes: reexamining data from the National Nursing Home Survey. Hosp Community Psychiatry. 1986;37:269-272. 7. Parmelee PA, Katz IR, Lawton MP. Depression among institutionalized aged: assessment and prevalence estimation. J GerontoL 1989;44:M22-M29. 8. Newman FL, Griffin BP, Black RW, Page SE. Linking level of care to level of need: assessing the need for mental health care for nursing home residents. Am Psychol. 1989;44:1315-1324. 9. Strahan GW, Bums BJ. Mental illness in nursing homes: United States, 1985. Vital Health Stat [13]. 1991;No. 105. 10. German PS, Rovner B, Bertner L, Brant LJ. The role of mental morbidity in the nursing home experience. Gerontologist. 1992;32:152-158. 11. Rovner BW, German PS, Brant LJ, Clark R, Burton L, Folstein MF. Depression and mortality in nursing homes. JAMA. 1991; 265:993-996. 12. Bienenfeld D, Wheeler BG. Psychiatric services to nursing homes: a liaison model. Hosp Community Psychiatry. 198W: 793-794. 13. Tourigny-Rivard M-F, Drury M. The effects of monthly psychiatric consultation in a nursing home. Gerontologist. 1987;27: 363-366. 14. Sholomskas AJ, Chevron ES, Prusoff BA, Berry C. Short-term interpersonal therapy (IPFT) with the depressed elderly: case reports and discussion. Am J Psychother. 1983;37:552-566. 15. Crook T, Bartus RT, Ferris S, Gershon S, eds. TreatmentDevelopmentStrategiesfor Alzheimer's Disease. Madison, Conn: Mark Powley Associates; 1986. 16. The elderly remain in need of mental health services. Washington, DC: US General Accounting Office; 1982. HRD-82-112. 17. Beardsley RS, Larson DB, Burns BJ, Thompson JW, Kamerow DB. Prescribing of psychotropics in elderly nursing home patients. JAm Geriatr Soc. 1989;37:327330. 18. Buck JA. Psychotropic drug practice in nursing homes.JAm Genatr Soc. 1988;36: 409-418. 19. Bums BJ, Kamerow DB. Psychotropic drug prescriptions for nursing home residents. J Fam Pract. 1988;26:155-160. 20. Ray WA, Federspiel CF, Schaffner W. A study of antipsychotic drug use in nursing homes: epidemiologic evidence suggesting misuse. Am JPublic Health. 1980;70:485491. 21. Andersson M. Drugs prescribed for elderly patients in nursing homes or under medical home care. ComprGerontoL 1989;(supplA + B)3:8-15. 22. Crook T, Ferris 5, Bartus R, eds. Assessment in Geriatric Psychophannacology. New Canaan, Conn: Mark Powley Associates; 1983. 23. Andersen R, Aday LA. Access to medical
March 1993, Vol. 83, No. 3
Mental Health Service Use in Nursing Homes care in the US: realized and potential. Med Care. 1978;16:533-546. 24. Knesper DJ, Wheeler JRC, Pagnucco DJ. Mental health services providers' distribution across counties in the United States. Am PsychoL 1984;39:1424-1434. 25. Cleary PD. The need and demand for mental health services. In: Taube CA, Mechanic D, Hohmann A, eds. The Future of Mental Health Se,vices Research. Washington, DC: US Government Printing Office; 1989. DHHS publication ADM 891600. 26. Strahan GW. Preliminary data from the 1985 National Nursing Home Survey.Adv Data Vital Health Stat. 1987;No. 131. 27. Hing E. Use of nursing homes by the elderly: preliminary data from the 1985 National Nursing Home Survey.AdvData Vital Health Stat. 1987; No. 135.
March 1993, Vol. 83, No. 3
28. Leaf PJ, Bruce ML, Tischler GL, Freeman DH, Weissman MM, Myers JK Factors affecting the utilization of specialty and general medical mental health services. Med Care. 1988;26:9-26. 29. Wijesinha A, Begg CB, Funkenstein MD, McNeil BJ. Methodology for the differential diagnosis of a complex data set: a case study using data from routine CT scan examinations. Med Decis Makdng. 1983;3: 133-154. 30. Goldstrom ID, Bums BJ, KesslerLG, etal. Mental health services use by elderly adults in a primary care setting.JGerontoL 1987; 42:147-153. 31. George LK, Landerman R, Blazer DG, Anthony JC. Organic mental disorders and cognitive impairment. In: Robins LN, Regier DA, eds. Psychiatic Disorders in America. New York, NY: Free Press;
1991:314-316. 32. Rovner BW, German PS, Broadhead J, et al. The prevalence and management of dementia and other psychiatric disorders in nursing homes. Int Psychogenatr. 1990;2: 13-24. 33. Fogel BS, Furnino A, Gottlieb GL, eds. Mental HealthPolicyforOlderAmencans: Protecting Minds at Risk. Washington, DC: American Psychiatric Press; 1990. 34. Institute of Medicine. Improving the Quality ofCare in Nursing Homes. Washington, DC: National Academy Press; 1986. 35. Dial TH, Tebbutt R, Pion GM, et al. Human resources in mental health. In: Manderscheid RW, Sonnenschein MA, eds. Mental Health, United States, 1990. Washington, DC: US Government Printing Office; 1990. DHHS publication ADM 901708.
American Journal of Public Health 337