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Chapter 20

Sources of Referral for Persons Admitted to Specialty Mental Health Organizations, United States, 1997

Raquel A. Crider, Ph.D.
Laura J. Milazzo-Sayre
Daniel J. Foley, M.S.
Ronald W. Manderscheid, Ph.D.
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration

Beatrice G. Blacklow, M.P.H.
Alisa A. Male, M.A.
Synectics for Management Decisions, Inc.

Introduction

The aim of this chapter is to describe the referral source for adults and children admitted to inpatient and outpatient mental health programs using a nationally representative 1997 Client/Patient Sample Survey. The President's New Freedom Commission on Mental Health report of 2003 found widespread fragmentation in mental health services that causes clients to slip through interorganizational "cracks (NFCMH, 2003)." According to the report, a goal of transforming the mental health system is to ensure that "early mental health screening, assessment, and referral to services are common practice." The Institute of Medicine's (IOM) 2001 Crossing the Quality Chasm report identified several aims for the redesign of the American health care systems (IOM, 2001). Core to the IOM report are that appropriate and safe, person-centered, efficient, effective, equitable, and timely based referrals be made (Adams, Daniels, & Reis, 2005). A major step in achieving the goal of early and appropriate referral is to describe the pattern of referrals using a nationally representative database.

This chapter offers a framework for understanding organizational interactions in the provision of care that is continuous and appropriate for persons with mental illness. It describes the sources of referral for persons admitted to the specialty mental health care delivery system and documents how the mental health system interacts with other delivery systems—health (e.g., emergency rooms, private physicians), social services (e.g., social service agencies, schools), correctional agencies (e.g., courts, police), as well as interactions among mental health care providers (e.g., psychiatric hospitals, outpatient clinics).

Data Source

In 1997, the Client/Patient Sample Survey (1997 CPSS) was conducted by the Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA) (SAMSHA, 1997). The 1997 CPSS represented a nationwide cross-sectional sample survey of persons admitted to and receiving care in specialty mental health organizations. The survey was designed to collect statistical information on the demographic, clinical, and service use characteristics of the population receiving mental health care, and to provide national estimates of this population. The 1997 CPSS included a sample of persons admitted to a sample of programs of specialty mental health organizations. The following types of organizations were included: State and county mental hospitals, private psychiatric hospitals, separate psychiatric services of the Department of Veterans Affairs (VA) medical centers and of non-Federal general hospitals, multiservice mental heath organizations, residential treatment centers for emotionally disturbed children, other residential programs, and freestanding outpatient clinics and partial care organizations. The types of programs included inpatient, residential, and outpatient. Outpatient refers to less than 24-hour care programs that provide outpatient and partial care services that are not overnight. Details about the design and scope of the 1997 CPSS can be found in appendix B of this volume.

This chapter presents findings from the 1997 CPSS that highlight the referral source most responsible for a person's admission to selected program types providing specialty mental health care. The chapter provides an analysis of the following:

Admissions of adults (age 18 and older) and children (under age 18), with respect to level of care: inpatient programs (excluding residential care) and outpatient programs of specialty mental health organizations, by source of referral: personal, community setting, outpatient setting, or inpatient/residential setting.

Personal referral includes self and family/friends. Community setting includes social services agency, court or corrections agency (except police), police, educational system, and other community setting. Outpatient setting includes private practice mental health professional, outpatient mental health care program, general medical program or physician, alcohol/drug abuse treatment facility, and other outpatient program or care. Inpatient/residential setting includes State or county mental hospital, general hospital inpatient psychiatric services, other psychiatric hospital or inpatient psychiatric service, hospital medical service, alcohol/drug abuse treatment facility, residential setting (e.g., group home, halfway house), and other inpatient or residential setting.

Method

Estimates of standard errors were calculated through the use of SUDAAN Survey Data Analysis Software (Shah, Barnwell, Hunt, & LaVange, 1995). This procedure computes estimated standard errors through the use of the Taylor series approximation. As applied to data from the present survey, variance estimates for totals and subtotals were calculated for each sampling stratum and then summed across sampling strata to derive standard errors for characteristics of interest.

A logistic regression analysis was used to examine the factors associated with admission to inpatient mental health programs within the specialty mental health system. The independent variables in the model included age (adults age 18 and older versus children under age 18); gender (males versus females); race (Black or African American, Hispanic or Latino and others, versus White); diagnosis (schizophrenia, adjustment disorders, or affective disorders versus other diagnoses); and referral source (personal, community setting, or outpatient setting versus inpatient/residential setting).

Results

Table 20.1 shows the demographic characteristics of inpatient and outpatient admissions for mental health services, as well as the demographics for the U.S. civilian population in 1997. There were an estimated 2.0 million inpatient admissions and 3.3 million outpatient admissions in 1997.

Overall, males comprised the majority of inpatient admissions (54 percent) while they comprised 49 percent of the U.S. civilian population. For outpatient admissions, males and females were admitted in about the same proportion as in the U.S. civilian population (Males accounted for 49 percent of outpatient admissions and the U.S. civilian population; females accounted for 51 percent of outpatient admissions and the U.S. civilian population).

Children under age 18 comprised 14 percent of inpatient admissions, 29 percent of outpatient admissions, and 26 percent of the U.S. civilian population in 1997. The race/ethnicity distribution shows that inpatient admissions were 70 percent White, 19 percent Black or African American, 9 percent Hispanic or Latino, 1 percent Asian or Pacific Islander, and 1 percent American Indian or Alaska Native. A similar distribution was found for outpatient admissions, who were 70 percent White, 17 percent Black or African American, 10 percent Hispanic or Latino, 2 percent Asian or Pacific Islander, and 1 percent American Indian or Alaska Native. In the U.S. civilian population, 73 percent were White, 12 percent Black or African American, 11 percent Hispanic or Latino, 4 percent Asian or Pacific Islander, and 1 percent American Indian or Alaska Native.

Referral Source—Major Groups

Figure 20.1 shows the distribution of adult admissions by referral source within major groupings (personal, community, outpatient, and inpatient/residential) by level of care (inpatient treatment and outpatient treatment). For adults, the personal referral source was the most frequently reported group for both inpatient and outpatient admissions (38 percent and 45 percent, respectively) (figure 20.2). Child inpatient admissions were distributed almost uniformly among all four referral groups (27 percent, 25 percent, 27 percent, and 21 percent, respectively). Child outpatient admissions were distributed primarily among the personal referral group (40 percent) and the community setting referral group (38 percent).

Referral Source—Specific Types Within Major Groups

The most frequent referral source occurs in the personal referral category. About a third of the adults have referrals from family or friend. Between about 30 percent and 40 percent of the children are referred by family or friend. As would be expected, children seldom refer themselves for care.

• Adults referred to inpatient care: 25 percent were referred by self, and 12 percent were referred by family or friend (table 20.2).



• Adults referred to outpatient care: 36 percent were referred by self, and 9 percent were referred by family or friend (table 20.2).



• Children referred to inpatient care: 27 percent were referred by family or friend (table 20.3).



• Children referred to outpatient care: 38 percent were referred by family or friend (table 20.3).

Other frequently mention referral sources include courts or corrections agency, social service agency, private practice mental health professional, general medical program or physician, and educational system.

• Adults referred to inpatient care: 10 percent were referred by police, and 10 percent were referred by outpatient mental health care program (table 20.2).



• Adults referred to outpatient care: 9 percent were referred by court or corrections agency (table 20.2).



• Children referred to inpatient care: 10 percent were referred by a social service agency, 12 percent were referred by a private practice mental health professional, and 9 percent were referred by a general medical program or physician (table 20.3).



• Children referred to outpatient care: 17 percent were referred by court or corrections agency, and 13 percent were referred by the educational system (table 20.3).

Personal Group. Among adult admissions to inpatient and outpatient care with a personal referral, the most frequently reported referral source was self (25 percent and 36 percent, respectively, table 20.2). For child admissions to inpatient and outpatient care, the most frequently reported referral source was family or friend (27 percent and 38 percent, respectively, table 20.3).

Community Setting Group. Within the community setting referral group for adults (table 20.2), no specific referral source is predominant. Police referrals represent 10 percent of referrals for adult inpatient admissions, and court or corrections agency (except police) represents 9 percent. Social service agency referrals account for 10 percent of referrals provided to children admitted to inpatient care and 17 percent to outpatient care (table 20.3). Almost 13 percent of referrals for children admitted to outpatient services come from the educational system.

Outpatient Setting Group. Among adults admitted to inpatient care, significant differences were not found in the proportions referred by a private practice mental health professional, outpatient (OP) mental health care program, or general medical program or physician (table 20.2). This finding also held true among children admitted to inpatient care (table 20. 3). A higher proportion of adult admissions to outpatient care received referrals from OP mental health care programs (6 percent) and general medical program or physician (7 percent) compared with other sources within the outpatient setting group. Among children admitted to outpatient care, a higher proportion receive a referral from a general medical program or physician (8 percent) than from other sources within the group.

Inpatient/Residential Setting Group. Within this group, the most frequently reported referral source for adults admitted to inpatient programs was a hospital medical service (8 percent; table 20.2), constituting nearly half of the 18 percent referred from all inpatient/residential settings. General hospital inpatient psychiatric service (6 percent) was the most frequently reported source of referral for adults admitted to outpatient care. In table 20.3, a nearly equal distribution of referrals from residential setting (6 percent), other psychiatric hospital or inpatient psychiatric service (5 percent), and hospital medical service (5 percent) was found for children admitted to inpatient care. For children admitted to outpatient care, no referral source dominated.

Referral Source by Type of Organization

Adults admitted for inpatient and outpatient care at VA medical centers were primarily referred by themselves or family and friends—personal referral (67 percent for inpatient, 66 percent for outpatient; table 20.4). This finding is contrasted with 10 percent personal referrals for adults admitted to inpatient State/county hospitals.

For children admitted for outpatient care at State/county hospitals, 51 percent were referred from a community setting, primarily courts and correction agencies. The same applies for outpatient residential treatment centers (RTCs), where 52 percent of the children admitted were referred by a community setting.

Multivariate Analyses

Logistic regression was used to examine the odds of being referred to an inpatient program versus an outpatient program based on age, sex, race/ethnicity, diagnosis, and referral source. Table 20.5 shows that adults are twice as likely as children to be referred for inpatient care (odds ratio = 2.00). Males are 30 percent more likely than females to be referred to an inpatient program (odds ratio = 1.30). Persons diagnosed with schizophrenia are more than twice as likely as persons diagnosed with "other disorders" to be referred to an inpatient program (odds ratio = 2.27), and persons diagnosed with affective disorders are 72 percent more likely to enter inpatient programs than those with "other disorders" (odds ratio = 1.72). In contrast, persons diagnosed with adjustment disorders are less likely to enter an inpatient program than those diagnosed with "other disorders " (odds ratio = 0.40). Clients with a personal referral source are more likely to be referred to an outpatient program than the reference group, persons with an inpatient referral source (odds ratio = 0.73). The likelihood of being admitted for inpatient care was not associated with race/ethnicity.

Discussion

The 1997 CPSS data showed that 1.7 million adults were admitted to an inpatient mental health program and 2.4 million to an outpatient program. These figures represent approximately 2 percent of the 197 million civilian population in 1997. More than a quarter of the adults were self referred, an indicator of the extent of consumers' involvement in directing their own services. The concept of self-directed services supports Goal 2 of the President's New Freedom Commission report, which focuses on consumer driven mental health services.

Interaction between mental health providers and providers of general medical care is evident in the 1997 CPSS data. Approximately one in five admissions for inpatient specialty mental health care were referred from other inpatient settings, and the majority of these referrals were from a general hospital's medical service. This finding highlights the link between inpatient mental health care and inpatient general hospital care, in support of Goal 1 of the President's New Freedom Commission report, addressing the necessity of linkages between mental and physical health care.

While physicians are generally knowledgeable about mental health treatment strategies (Katerndahl & Ferrer, 1995), some research suggests that referrals from hospitals and physicians are less frequent than needed (Lee, Brasel, & Lee, 2004). Lee and colleagues (2004) found that more than half of emergency care practitioners generally do not refer trauma patients for mental health follow-up because the practitioners lack the time to consider such a referral, or because the symptoms are not obvious. Lee and colleagues (2004) concluded that there needs to be additional training and screening related to mental health problems in trauma patients. Weis and Grunert (2004) reinforced the need for mental health screening and suggested that utilization of a physician screening tool following traumatic injuries might be helpful in making mental health referrals. Other factors physicians are encouraged to consider in an appropriate referral for mental health services are family involvement, type of insurance, and diagnosis (White, Bateman, Fisher, & Geller, 1995).

Courts or corrections agencies constitute an important referral source for patients entering State/county mental hospitals and a less important source for the private psychiatric hospitals or non-Federal general hospitals, suggesting a difference in referral source by ownership of the mental health organization—public vs. private. Using data from the 1975 and 1980 CPSS, Nakao, Milazzo-Sayre, Rosenstein and Manderscheid (1986) found a relationship between ownership of mental health organizations and referral from court or corrections agencies, with publicly owned programs receiving a larger proportion of court or corrections referrals than privately owned facilities.

Few referrals in the 1997 CPSS are reported from "other community settings." These other settings, consisting of nontraditional and non-health-related services such as self-help groups or spiritual advisors, were found to be important treatment venues (Wang et al., 2005). Van Citters and Bartels (2004) reviewed the literature on referrals to community-based mental health outreach services for older adults and found that gatekeepers and nontraditional referral sources were effective in identifying socially isolated older adults in need of mental health services. With so few referrals from "other community settings," these important sources may be overlooked.

Based on data from the 1997 CPSS, 300,000 children were admitted to inpatient programs and 1.0 million were admitted to outpatient programs, representing nearly 2 percent of the 70 million children in the Nation in 1997. Of the 1.3 million children admitted to specialty mental health organizations, approximately half of the children receiving outpatient services and a quarter of those receiving inpatient services were referred by their families. Pottick and Davis (2001) found that the family members were particularly skilled in finding mental health resources.

Referral to an inpatient or outpatient program is often related to severity of the problem at the time of referral. Using the 1997 CPSS data, Pottick and colleagues (2004) showed that, for children entering the mental health system, severity of the illness is associated with the level of care to which the child is referred. According to their findings, more than half of children with a Global Assessment of Functioning (GAF) score of 50 or less were referred to an inpatient program, while only about a third with that score were referred to an outpatient program. A GAF score of 50 represents a serious degree of impairment in functioning in most social areas; scores less than 50, more severe impairment.

Approximately 28,000 children in inpatient programs and 164,000 children in outpatient programs were referred by social service agencies. Hurlburt and colleagues (2004) suggest that more children may need to be referred for mental health services. This study examined specialty mental health service use for 1 year after contact with child welfare, using a nationally representative cohort of 2,328 children aged 2 to 14 in 97 U.S. counties. Their data showed that only 28 percent of children involved with the child welfare system received specialty mental health services during the year, although 42 percent had a clinical-level Child Behavior Checklist indicating the need for referral.

The 1997 CPSS data have some limitations. The data were collected in 1997, and social trends and policy changes since that time may have influenced current referrals to specialty mental health organizations. The CPSS data do not capture other factors that might be related to a referral, such as family resources or geographic distance to a facility. Many children are treated for mental health disorders secondary to substance abuse problems. If these children were treated in dedicated substance abuse programs, they would not be included in the 1997 CPSS. However, substance-abusing youth with co-occurring disorders treated in specialty mental health programs would be included in the sample. Also, the CPSS excludes persons seen by psychiatrists in private practice and those receiving care from private counseling or psychotherapy service providers.

Summary

Approximately 2 percent of the general civilian population is treated in specialty mental health organizations. Personal referral is the most frequently mentioned referral category for both adults and children. General medical programs or physicians and hospital medical services are important referral sources for persons admitted to inpatient mental health care, showing the importance of and need for interactions between mental and physical health care providers. Referrals from courts or corrections agencies may be related to the ownership of the organization to which the client is referred, with the greater proportion of court or corrections referrals going to public facilities and a smaller proportion going to private ones.

References

Adams, N., Daniels, A., & Reis, S., with guest editors Manderscheid, R. W., Daniels, A., Adams, N., & Carroll, C. D.(2005). Transformation of the mental health system using quality as a lever for change in transforming mental health. International Journal of Mental Health, 34(1),10-25.

Hurlburt, M. S., Leslie, L. K., Landsverk, J., Barth, R. P., Burns, B. J., Gibbons, R. D., et al. (2004). Contextual predictors of mental health service use among children open to child welfare. Archives of General Psychiatry, 61(12),1217-1224.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Katerndahl, D., & Ferrer, R. L. (2004). Knowledge about recommended treatment and management of major depressive disorder, panic disorder, and generalized anxiety disorder among family physicians. Primary Care Companion of the Journal of Clinical Psychiatry, 6(4), 147-151.

Lee, S., Brasel, K., & Lee, B.(2004). Emergency care practitioners' barriers to mental health assessment, treatment, and referral of post-injury patients. Wisconsin Medical Journal, 103(6), 78-82.

Nakao, K., Milazzo-Sayre, L. J., Rosenstein, M. J., & Manderscheid, R.W. (1986). Referral patterns to and from inpatient psychiatric services: A social network approach. American Journal of Public Health, 76(7), 755-760.

Pottick, K. J., & Davis, D. J. (2001). Attributions of responsibility for children's mental health problems: Parents and professionals at odds. American Journal of Orthopsychiatry, 171(4), 426-435.

Pottick, K. J., Warner, L. A., Isaacs, M., Henderson, M. J., Milazzo-Sayre. L., & Manderscheid, R. W.(2004). Children and adolescents admitted to specialty mental health care programs in the United States, 1986 and 1997. In R. W. Manderscheid & M. J. Henderson (Eds.) Mental health, United States, 2002 (pp. 314-326) (DHHS Pub No. (SMA) 3938). Rockville, MD: Substance Abuse and Mental Health Services Administration.

President's New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental care in America. Final report (DHHS Pub. No. SMA-03-3832). Washington, DC: Department of Health and Human Services. Available at www.mentalhealthcommission.gov/reports/FinalReport/toc.html.

Shah, B. V., Barnwell, B. G., Hunt, P. N., & LaVange, L. M. (1995). SUDAAN Reference Manual, Release 6.40. Research Triangle Park, NC: Research Triangle Institute.

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Wang, P. S, Lane, M., Olfson, M., Pincus., H. A., Wells, K. B., & Kessler, R. C. (2005). Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 629-639.

Weis, J., & Grunert, B. K. (2004). Post-traumatic stress disorder following traumatic injuries in adults. Wisconsin Medical Journal, 103(6), 41-42.

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