Social Determinants of Mental Health Care Systems: Intensive Community Based Care in The Veterans Health Administration

doi:10.21203/rs.3.rs-21906/v2

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Social Determinants of Mental Health Care Systems: Intensive Community Based Care in The Veterans Health Administration

https://doi.org/10.21203/rs.3.rs-21906/v2

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published 28 Aug, 2020

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Background: Since deinstitutionalization in the 1950s-1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health. Analysis of the place of community-based programs within a comprehensive health system such as the Veterans Health Administration (VHA) may illuminate the role of social forces in shaping contemporary public mental health systems. Methods: National VHA administrative data were used to compare veterans who exclusively received outpatient clinic care to those receiving four types of specialized community-based services, addressing: 1) functional disabilities from severe mental illness (SMI), 2) justice system involvement, 3) homelessness, and 4) vocational rehabilitation. Bivariate comparisons and multinomial logistic regression analyses compared groups on demographics, diagnoses, service use, and psychiatric prescription fills. Results: An hierarchical classification of 1,386,487 Veterans who received specialty mental health services from VHA in Fiscal Year 2012, showed 1,134,977 (81.8%) were seen exclusively in outpatient clinics; 27,931 (2.0 %)received intensive SMI-related services; 42,985 (3.1%) criminal justice services; 160,273 (11.6%) specialized homelessness services; and 20,921 (1.5%)vocational services. Compared to those seen only in clinics, veterans in the four community treatment groups were more likely to be black, diagnosed with HIV and hepatitis, had more numerous substance use diagnoses and made far more extensive use of mental health outpatient and inpatient care. Conclusions: Almost one-fifth of VHA mental health patients receive community-based services prominantly addressing major social determinants of health and multimorbid substance use disorders.

Health Economics & Outcomes Research

Infectious Diseases

Health Policy

Social Determinants

Mental Health Care Systems

Intensive Community Based Care

in Veterans Health Administration

Care for people with psychiatric disorders has undergone extraordinary changes in the past 70 years from a focus on asylum care to a “de facto” system of diverse, largely non-instiutional services [1-3]. A distinctive feature is the provision of community-based often intensive services for the most vulnerable, those long thought to be the most inadequately served [4]. In 1950, care for people with SMI, provided in over 500,000 state mental hospital beds [5], and was a target of public scorn [6]. By 1970, the majority of these beds had been closed and acute care was provided primarily in general hospitals, with longer term institutional care in nursing and board and care homes [7], and outpatient care in public clinics bolstered by newly developed antipsychotic and other psychiatric medications. By 1980, a substantial academic literature had developed decrying the failures of de-institutionalization and the neglect of people with the greatest needs [8]. Researchers showed that Assertive Community Treatment (ACT) [9] and other forms of intensive community-based care could provide humane services in non-instituional settings [10] at little or no additional cost [11]. Here too, critics claimed programs were under-funded [12]. Specialized psychiatric rehabilitation services were also developed to restore community adaptation and productive functioning [13-15], but these services were also believed to be of limited availability [16,17].

In the 1980s an unanticipated crisis of homelessness emerged. Initially viewed as a failure of deinstitutionalization because many homeless adults had SMI [18], it was eventually recognized to be more a consequence of the loss of affordable housing and the decline in public income support [19,20] - a one-two punch that fell hard on people with SMI and addictions [21]. This highly visible subgroup of homeless adults was recognized to need income, housing and specialized community outreach services as well as psychiatric care.

In an apparent rebound of institutionalism, the criminal the justice system exploded, in large part due to harsh new drug laws, and became an unwanted new asylum for people with psychiatric disorders representing, to many, a de facto criminalization of mental illness [22-24]. In response, diversion programs were designed to create a channel from the criminal justice system to mental health services [25].

The current system of community-based care for people with SMI thus developed in response both biomedical innovations and what has increasingly been referred to as social determinants of mental health [26] (i.e. social determinants of mental illness) [27-29]. The result has been a non-institutional system composed of two broad components: a standard clinic-based component backed by a limited hospital capacity, that serves the majority of patients, providing medications and behavioral therapies; and a second, outwardly facing, community focused component providing more resource intensive services to patients most impacted by “social determinants” and in need of specialized in vivo care. These community-based services were initially conceptualized as replacing care previously provided by state hospitals, but, as suggested above, they also emerged in response to a broad array of social and economic developments.

The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) is a nationally integrated health system with a specific mission to provide comprehensive healthcare to veterans of military service [30]. In many ways VHA mental health care has followed the same evolution as outlined above in other public mental health systems, adopting the same biomedical innovations and responding to the same social phenomena with specialized services. The VHA, however, is distinctive in that its electronic health records system comprehensively document sociodemographic characteristics and clinical diagnoses as well as service use and prescribed medications. VHA data thus offer a unique opportunity to examine place of intensive community-based mental health services in a 21^st century system of care and the veterans it serves.

This study uses national VHA data on 1.3 million veterans who received specialized mental health services from VHA in FY 2012, 240,000 (18%) of whom received often intensive community-based services that can be classified in four types: 1) ACT-like intensive case management and recovery-oriented day program services for veterans disabled by serious mental illness (SMI) [31,32] [33]; 2) outreach service to veterans involved in the criminal justice system [34-37]; 3) outreach and housing services for homeless veterans [38-42], and 4) rehabilitation and community-based employment services [43-45]. The primary goal of the criminal justice programs was outreach and linkage to standard VHA outpatient services. We included these programs in this study because of they represent a community-based service related to social problems as well as medical/psychiatric ones. In fact, historically, these programs were an outgrowth of the development of community-based programs for homeless veterans, many of whom have criminal justice problems. While these programs have been studied individually, no studies have taken a broad view of the development of community-based programs within the VHA mental health care system and examined the characteristics of veterans served by these programs together in a single analysis that examined their relative size and compared their participants to veterans served by standard outpatient clinics.

In this study veterans receiving these four specialized community-based services are compared to those who received only clinic-based services on socio-demographic and diagnostic characteristics and on patterns of mental health and medical service use. While a proportion of veterans were served by multiple programs, our primary intention was to describe how these programs can be understood together as a community-based response to diverse social determinants of health. We further compare the veterans they serve to those treated in standard outpatient mental health clinics. Intensive community-based services for veterans, particularly case management services, were originally designed to provide psychiatric treatment to people with SMI. Our central observation is that the VHA responded to the social determinants of veteran health in the community and designed programs to serve these veterans in vivo where their complex social issues arose. In this process it reached out to veterans with distinctive mental health problems characterized by behavioral multimorbidities that could be addressed by one or another, or sometimes by more than one of these programs.

There has been particular interest in recent years in multi-morbidity, the co-occurrence of mutually exacerbating psychiatric, substance use and medical disorders which are responsible for severe functional impairments and place extensive demands on health care systems [46,47]. We sought to pay simultaneous attention to both social determinants of health and clinical multi-morbidity in an examination of factors that might illuminate the place of intensive community-based programs in contemporary mental health service delivery.

Sample

Using national VHA data from FY 2012, a total of 1,386,487 veterans were identified who had used specialty mental health care. These veterans were classified into groups by the types of services they received. Community based services include those predominantly delivered outside the offices of the health care system to directly address social risks to health such as homelessness, incarceration, poor social functioning, poverty, and lack of employment skills. These services are not always provided outside of health system facilities, but they are all heavily focused on practical skills, supports for community living, and addressing individual social as well as medical circumstances. Since some veterans receive services from multiple programs, we classified them hierarchically, for analytic purposes, in mutually exclusive categories, including first, the most intensive long-term programs for SMI, followed by the two outreach programs addressing veterans involved in the criminal justice system and/or who were homeless, and then psychiatric rehabilitation programs, often provided as an ancillary to other clinical services. The remaining group was veterans seen only in office-based outpatient clinics. Thus while some veterans were treated in more than one community program (21.3% of those seen in any community program), they were only included in one comujnity treatment group in our analytic classification and most veterans seen in intensive community based programs (62.2%) were also seen in clinic settings.

Measures

Measures, obtained from a pre-constructed dataset from the Northeast Program Evaluation Center, documented sociodemographic variables including age, sex, race, geographic residence (urban or rural), national region, income, VA pension status, service-connection disability status (VA income support programs), and homelessness in the past year (identified through use of specialized homeless services and the V60 ICD9 code). Geographic measures were obtained through zip codes using the Rural-Urban Commuting Area classification [48].

Medical diagnoses were selected based on those included in the Charlson comorbidity index, an aggregate measure of comorbidity that predicts 1-year mortality using a weighted sum of medical comorbidities [49]. In addition to the Charlson index itself, medical diagnoses known to be associated with mental illness and substance use were included, such as hepatic disease, human immunodeficiency virus infection (HIV) and pain diagnoses, using an array of codes described elsewhere [50].

Psychiatric diagnoses included schizophrenia, bipolar disorder, major depressive (ICD-9

296.2-296.39) and other depressive disorders (ICD-9 300.4x, 296.9x, 301.10-301.19, 311.x), posttraumatic stress disorder (ICD-9 309.81), anxiety disorders (ICD-9 300.xx excluding 300.4), and personality disorders (ICD-9 301.9). In addition, 7 drug use disorders were included in the analysis: opiate (ICD-9 304.0x or 305.5), cannabis (ICD-9 304.3x or 305.2), cocaine (ICD-9 304.2x or 305.6), barbiturates (ICD-9 304.1x), amphetamines (ICD-9 304.4x or 305.7), and hallucinogens (ICD-9 304.5x or 305.3).

As a measure of multi-morbidity, summary variables were created as a count of the number of medical diagnoses, psychiatric diagnoses, and substance use diagnoses, and the total number of psychiatric and substance use diagnoses.

VHA outpatient health service utilization was derived from clinic stop codes (specific codes are available upon request) representing general psychiatric care, substance use specialty care, primary care, emergency department visits, and each of the four types of community psychiatric care.

Psychotropic medication fills were classified as antipsychotics, antidepressants, anxiolytic/sedative/hypnotics, stimulants, anticonvulsants/mood stabilizers and lithium.

Analysis

Bivariate analysis were used to compare veterans treated only in mental health clinics to those who received services from each of the four hierarchically classified types of intensive community based services.

Because the subgroups examined in involve many tens of thousands of Veterans, small group differences with little clinical importance would likely be statistically significant. We thus relied on effect sizes to identify substantial differences between groups. Cohen’s d was calculated for continuous variables (the difference in means between groups divided by their pooled standard deviation); and risk ratios for dichotomous variables representing proportions. A cutoff value of >0.20 or <-0.20 was used as a threshold for at least a small difference in Cohen’s d [51] and risk ratios of >1.5 or <0.67 for dichotomous variables.

Multinomial logistic regression analysis was then used to identify the set of measures that independently differentiated veterans who had been treated in each of the four sub-specialty community health programs from those treated in mental health clinics only. Variables included in the multivariable analyses were those we had previously identified as being substantially different between the groups based effect size differences in bivariate comparisons.

All analyses were conducted using SAS statistical software (version 9.2; SAS Institute Inc., Cary, NC).

Among the total of 1,386,487 veterans who had received specialty mental health services, 252,110 (18.2%) received specialized intensive community-based services. In our unduplicated hierarchical classification 27,931 (2.0 %) were classified in the intensive SMI services group; 42,985 (3.1%) in the criminal justice outreach group; 160,273 (11.6%) in homelessness services; and 20,921 (1.5%) in vocational services.

Bivariate analysis showed that veterans treated in criminal justice, homeless and vocational programs were substantially younger than those seen exclusively in outpatient mental health clinics. Veterans in the employment program group but not in the SMI program group had lower incomes (see comparisons using Cohen’s d in the right hand columns of Table 1). Veterans seen in each of the four community-based programs were substantially more likely to be black, and less likely to be from isolated rural areas.

Veterans in the criminal justice, homeless and vocational program groups were all less likely to have a service-connected disability rating of 50% or more than those seen in clinics. There were few differences on the Charlson index of medical co-morbidity although those in vocational program group had a lower index of medical problems than those seen in clinics, and veterans treated in each of the four community program groups had greater risks of HIV and hepatic diagnoses.

Most dramatic were the substantially 2-3 times greater numbers with any drug or alcohol abuse or dependance diagnoses in all four community-based program groups as compared to the clinic group, with Cohen’s d’s of greater than 0.5 for the total number of such diagnoses and risk ratios for each specific drug and alcohol use diagnosis greater than 2.0 (Table 2).

Numbers of non-substance use psychiatric diagnoses were substantially greater in the SMI program group with Cohen’s d of .69 and fewer in the criminal justice programs with Cohen’s d of -.29. Individual diagnoses most strongly associated with the SMI programs included schizophrenia, and bipolar disorder. While proportions of veterans diagnosed with personality disorder were greater in all four community program groups than in outpatient clinics, they were 4 times more common in the SMI programs even though personality disorder is not considered a serious mental illness (Table 2).

Veterans in each of the four community program groups had far more psychiatric and substance use outpatient visits than those seen in outpatient mental health clinics (Table 3), and participants in the SMI and vocational programs had more general psychiatry visits over and above the visits to specialized community service programs themselves, and three times as many total mental health outpatient contacts (totaling 51.63/year) overall. Veterans in all community program groups were more likely to have been hospitalized for psychiatric treatment compared to those seen in mental health clinics alone. There were no substantial differences in primary care or medical specialty visits although veterans seen in the criminal justice and SMI programs were more likely to have had medical hospitalizations (Table 3).

Veterans served by the SMI program group also had three times as many psychotropic prescription fills as those only seen in outpatient clinics, but substantial differences in psychotropic prescription fills were not seen in association with other community-based programs. Veterans who received SMI services filled far more antipsychotic prescriptions.. There were no substantial differences in numbers of prescriptions for opiates (Table 3).

Multinomial logistic regression showed that, independent of other factors, veterans in the homeless and vocational program groups had lower incomes and were less likely to have a service-connected disability status of greater than 50% than those in the mental health clinic group. Veterans serviced by criminal justice programs had a lower total number of non-substance use psychiatric diagnoses (psychiatric multi-morbidity) whereas those in SMI programs had a substantially higher number of such diagnoses. Perhaps the most dramatic independent association was that Veterans in each of the four community program groups were diagnosed with more numerous substance use disorders than those in the clinic group (Table 4).

This study used national VHA data to compare the proportions and characteristics of the 82% of veterans treated exclusively in traditional mental health outpatient clinics to the 18% of veterans treated in VHA’s four major specialized community-based programs. Veterans treated in all four types of community programs were distinguished most strikingly, by being diagnosed with 2-3 times more numerous multimorbid substance use disorders, were more likely to have HIV and hepatic disease, to be from urban areas, of black race and also, as expected, had 3-13 times more mental health outpatient visits, most of which were in community-based programs themselves. Veterans served in the specialized programs for SMI veterans (only 2% of the total) were much more likely than clinic patients to be diagnosed with psychotic disorders, to manifest psychiatric multimorbidity and personality disorders and had 13 times more total visits, receiving over three times as many prescriptions for psychotropic medications.

In the decades after the closure of public psychiatric hospitals in the 1950s-70s, public mental health systems faced the question of how to address the broad needs of: 1) SMI patients who formerly would have been institutionalized, as well as the needs of emerging populations of 2) homeless people with mental illnesses; 3) criminal justice involved adults with mental health disorders; 4) veterans seeking rehabilitation/employment along with 5) a much larger group of people newly seeking effective care for less severe problems. The intensive community programs included in this study all originated in a push by VHA to develop care beyond the clinic in the community, primarily to better address the clinical challenges of SMI. At their inception, these programs were at times organizationally integrated [52] or co-located [53] together and with primary care services. While there has been extensive documentation of the reduction in long term State and VHA psychiatric hospital beds [54,55,5], and many studies of the growth of outpatient mental health treatment generally [56-58]; we know of no previous system-wide studies of the place of community-based services in any public mental health system nor of characteristics of people who use these services as compared to people served by standard outpatient clinics.

On the one hand, available studies have examined mental health service delivery in the US as a whole and have shown that “the system” faces major challenges with respect to the treatment engagement of people with serious mentally illness [54]. On the other, the National Comorbidity Survey (NCS) and NCS Replication show that between 1990 and 2003 basic treatment rates for people with mental illness increased significantly while the overall rates of mental illness did not change [55] although many remained underserved [56]. Additionally, among people with SMI, rates of any mental health treatment increased from 24.3% to 40.5% [55]. Furthermore, data from the Healthcare for Communities Survey showed an increase in mental health specialty treatment for people with SMI from 39% in 1997 to 51% in 2001 with an even larger increase (from 47% to 76%) for the subgroup who perceived a need for treatment [57]. These studie, however, did not examine community-based services, specifically, and most studies have focused on people with mild to moderate mental illness. For example, studies of the National Ambulatory Medical Care Survey found that treatment for depression tripled between 1987 and 1997 [58], and that most antidepressants are prescribed by primary care providers [59,60].

Local studies based on Medicaid data do show that community programs continued to provide ACT and ACT-like services to the most seriously mentally ill and functionally impaired adults [61], though one recent survey suggested that less than 20% of non-VA community mental health facilities offer ACT [62] and even fewer offer other community services such as peer support, employment, and housing services [63]. While most research has focused on either people who use less intensive services (i.e. from standard mental health outpatient clinics) or specific community-based treatments like ACT or supported housing, no study to our knowledge has addressed the broad array of clinic and intensive community-based services offered together in a national system or even in one community. The present study, based on VHA data showed intensive community-based service are provided to 18% of those receiving any specialty mental health services especially to those with multiple substance use disorders, severe mental illness, criminal justice involvement, and/or homelessness. A previous study of VHA care showed that considering all patients with psychiatric diagnoses, one-third receive no specialty mental health treatment at all and recieive care for mental disorders exclusively in primary or specialty care clinic setiings [64]. That study and this one taken together, thus appear to be unique in mapping the major components of VHA mental health care, a comprehensive mental health system in which most patients receive care in standard outpatient mental health and primary care clinics but distinct subgroups receive intensive community-focused care largely shaped by social determinants and SUD-related multimorbidity.

In view of this perspective, it is notable that several recent reviews have emphasized the unique role of mental health services in addressing social determinants of health as well as individual biomedical conditions [65,26,27]. The portrait of community-based care in VHA presented here illustrates the way mental health systems have been shaped by such social determinants. Sheilds-Zeeman described two types of intervention which are referred to as “social risk–informed” care and “social risk-targeted care.” Social risk–informed care tailors clinical plans to reduce the effect of social or economic adversity, most often in conventional clinic settings, without necessarily targeting the social condition itself. Social risk-targeted care, in contrast, more directly helps patients to reduce social or economic adversity, and is more focused on community intervention. The community-based programs described here fall into both categories in that they seek to provide in vivo services at the individual level focusing on real world adaptation to challenging circumstances while also directly addressing patient-level problems such as housing, criminal justice involvement, impaired activites of daily living, limited employment opportunities, social isolation and a stigmatizing environment. The developing conceptualization of mental health care within a social determinants of health framework, thus provides an overarching context for understanding the unique role of community-focused programs.

Several methodological limitations of this study require comment. First, our ability to identify services delivered through community-based programs is limited to those identified by specific clinic codes in VHA administrative records. It is likely that other programs in VHA that would conform to our concept of community-based care that were implemented through local initiatives, which we could not identify. However, those examined here were developed through national initiatives, often supported by special funding and are probably the largest and best definied. Perhaps the issue most neglected by this study is poverty, addressed by VA disability compensation and pension programs for many veterans. These programs were less commonly used by veterans served by outreach to criminal justice involved and homeless veterans although their access to these benefits likely increases after a period of program participation [66]. Crucial data are also not available on the income obtained from social security and local welfare programs.

Second, the definition of intensive community-based programs is not precise and while most programs addressed here involve frequent contact with veterans outside of health care facilities there is variability from program to program (e.g. criminal justice programs focus on linkage rather than intensive service delivery) and facility to facility in the extent of vivo as contrasted with office-based service delivery in these programs. Nevertheless, all of the programs are intended to address exceptionally serious clinical conditions and specific socially determined challenges to community adaptation.

Third, administrative diagnoses are not based on formal diagnostic instruments or criteria, but have the advantage of representing real-world clinical judgements.

Fourth, this study focuses on data from the VHA which offers the advantage of providing comprehensive national data from electronic health records. However VHA is federally funded and operated and serves only veterans, who are overwhelmingly male, and thus its generalizability to other populations and health systems is unknown. The extent to which veterans studied here received non-VA services is also unknown. This study offers a sketch of one system which, it is hoped, will stimulate similar studies of others.

Finally, the data used in this study are somewhat dated as they are now 8 years old. However, 2012 was closer than more contemporary data to the point in time when community-based services emerged in the VHA in response to emerging social needs of several subgroups of veterans. In addition, a recent study [67] found little change in the characteristics of homeless veterans treated by VHA from FY 2008 to FY 2015, a major segment of the population with social challenges that the VHA now serves through community-based programs..

This study could not describe each type of intensive community-based program offered by the VHA in detail but rather, summarized their primary service models and characterize the veterans they serve. We do provide data on the average number of contacts of each program with the veterans it serves.

In 2012, almost one-fifth of VHA mental health patients received specialized community-based services addressing, most distinctively, major social determinants of health and multimorbid substance use disorders. Deinstitutionalization of the 1950s-1970 s was followed by several other major social changes that stimulated the development of novel community-based public mental health services. While the effectiveness, and cost-effectiveness of these specialized services has been demonstrated in randomized trials [62, 36, 63, 25], evaluation of the acessabiity and effectiveness of such programs in the context of large regional and national service systems is a far more challenging task, and remains to be undertaken.

ACT - assertive community treatment

FY - fiscal year

HIV - human immunodeficiency virus

ICD - International Classification of Diseases

NCS - National Comorbidity Survey

SMI - severe mental illness

VA - Veterans Affairs

VHA - Veterans Health Administration

Ethics approval and consent to participate

The study was approved by the Institutional Review Board committee of the VA Connecticut Healthcare System. A waiver of informed consent was obtained as the study used administrative data and there were no patient identifiers included

Consent to publish

Not applicable

Availability of data and materials

The data that support the findings of this study are available from the Veterans Health Administration but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Veterans Health Administration.

Competing interests

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Funding

This work was funded by the U.S. Department of Veterans Affairs.

Authors' Contributions

RR and IB designed the study, and wrote and edited the manuscript. ES completed the data analysis. All authors contributed to and have approved the final manuscript

Acknowledgements

We have no acknowledgements.

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Table 1. Bivariate comparison of demographic characteristics of veterans in community care treatment and mental health clinics only. (1)

			Mental Health Clinic (1)		Vocational (2)		Homelessness (3)		Criminal Justice (4)		SMI Services (5)		2 vs 1	3 vs 1	4 vs 1	5 vs 1
		N=	1,134,377		20,921		160,273		42,985		27,931		Effect Size
Demographics			Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Cohen d
	Age (years)		55.22	15.45	48.69	12.30	52.15	12.01	52.18	15.64	54.02	11.96	-0.43	-0.20	-0.20	-0.08
	Income ($)		25,339.03	42,872.53	15,658.00	22,245.30	12,602.47	22,973.72	19,912.26	42,170.73	20,693.33	23,364.20	-0.24	-0.31	-0.13	-0.11
			%	N	%	N	%	N	%	N	%	N	Risk Ratio
	Male		90.3	1,024,217	89.7	18,766	90.5	145,034	94.5	40,611	88.5	24,714	0.993	1.002	1.046	0.980
	Race
		White	77.5	879,022	62.0	12,968	52.8	84,636	68.1	29,281	65.0	18,149	0.800	0.681	0.879	0.839
		Black	16.2	183,291	31.2	6,522	39.1	62,738	25.0	10,766	28.5	7,957	1.929	2.423	1.550	1.763
		Hispanic	17.0	192,678	14.7	3,079	12.6	20,138	11.8	5,059	10.0	2,789	0.867	0.740	0.693	0.588
		Mixed	2.1	23,692	2.5	516	2.7	4,356	2.1	910	3.2	898	1.180	1.301	1.014	1.540
		Other	1.6	18,251	1.2	247	1.1	1,716	1.4	606	1.7	473	0.733	0.665	0.876	1.054
	Residence type
		Urban area residence	68.8	780,219	78.9	16,499	85.0	136,183	76.5	32,877	81.4	22,737	1.147	1.235	1.112	1.184
		Large rural area residence	11.5	130,283	9.5%	1,979	6.7%	10,688	9.4%	4,057	8.3%	2,330	0.824	0.581	0.822	0.726
		Small rural area residence	8.9	100,520	5.1%	1,075	4.0%	6,372	6.7%	2,886	4.6%	1,297	0.580	0.449	0.758	0.524
		Isolated rural area residence	6.7	75,455	3.6%	756	2.6%	4,144	5.2%	2,233	2.7%	750	0.543	0.389	0.781	0.404
	OEF/OIF era		17.6	200,092	19.5	4,085	9.9	15,798	17.9	7,715	8.8	2,453	1.107	0.559	1.018	0.498
	Service connected 50% or more		39.1	444,072	20.2	4,227	15.0	24,062	20.5	8,830	43.2	12,074	0.516	0.384	0.525	1.104
	Service conneced <50%		18.9	214,572	19.7	4,117	17.0	27,195	16.1	6,907	11.7	3,264	1.040	0.897	0.849	0.618
	Homeless during the year		1.4	15,932	10.7	2,235	86.2	138,219	30.6	13,169	28.3	7,894	7.606	61.404	21.813	20.123

(1) Non-substantial differences involving less than 5% of the sample are notshown. Data available on request.

Table 2. Bivariate comparison of diagnoses of veterans in community care treatment and mental health clinics only. (1)

		Mental Health Clinic (1)		Vocational (2)		Homelessness (3)		Criminal Justice (4)		SMI Services (5)		2 vs 1	3 vs 1	4 vs 1	5 vs 1
	N=	1,134,377		20,921		160,273		42,985		27,931		Effect Size
		Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Cohen d
Multimorbidity
	Number of psychiatric diagnoses	1.79	1.11	1.87	1.42	1.60	1.49	1.43	1.53	2.62	1.483	0.067	-0.151	-0.294	0.688
	Number of SUD diagnoses	0.27	0.62	0.70	1.04	0.87	1.16	0.75	1.13	0.80	1.130	0.571	0.797	0.643	0.708
	Number of psychiatric and SUD diagnoses	2.05	1.33	2.56	1.91	2.47	2.18	2.18	2.27	3.42	2.068	0.332	0.272	0.084	0.885
	Charlson medical severity diagnosis index	2.81	2.44	1.96	1.99	2.32	2.16	2.45	2.53	2.80	2.185	-0.347	-0.199	-0.144	-0.001
Medical diagnosis		%	N	%	N	%	N	%	N	%	N	Risk Ratio
	Insomnia	8.2	92,536	8.3	1,736	6.6	10,592	6.3	2,709	6.6	1,830	1.017	0.810	0.773	0.803
	Congestive heart failure	48.7	552,483	47.4	9,911	48.6	77,896	46.0	19,793	61.5	17,184	0.973	0.998	0.945	1.263
	Chronic obstructive pulmonary	14.8	167,951	12.5	2,623	14.7	23,540	14.3	6,165	19.4	5,412	0.847	0.992	0.969	1.309
	Diabetes mellitus	23.3	264,173	16.7	3,487	17.0	27,240	16.9	7,283	27.0	7,535	0.716	0.730	0.728	1.158
	Cancer	7.2	81,768	3.9	822	5.1	8,208	6.2	2,677	5.8	1,619	0.545	0.710	0.864	0.804
	Human immunodeficiency virus	0.5	6,226	1.4	287	1.5	2,420	0.9	369	1.0	275	2.499	2.751	1.564	1.794
	Headache	9.5	107,605	12.0	2,514	8.8	14,084	8.4	3,610	10.5	2,926	1.267	0.926	0.885	1.104
	Any pain	56.2	637,256	63.0	13,186	58.4	93,525	52.7	22,673	61.1	17,054	1.122	1.039	0.939	1.087
Psychiatric Diagnosis
	Any psychiatric disorder	92.2	1,045,820	85.9	17,972	78.2	125,382	68.4	29,403	99.4	27,757	0.932	0.849	0.742	1.078
	Schizophrenia	4.8	54,401	6.5	1,367	6.3	10,148	3.9	1,662	47.8	13,360	1.362	1.320	0.806	9.974
	Other psychotic disorder	2.5	28,651	3.8	801	4.4	7,094	3.6	1,529	13.9	3,878	1.516	1.752	1.408	5.497
	Bipolar disorder	6.9	78,011	11.2	2,333	9.0	14,406	7.5	3,236	22.9	6,395	1.622	1.307	1.095	3.329
	Major depressive disorder	21.1	239,616	22.9	4,799	17.1	27,390	13.9	5,987	26.9	7,512	1.086	0.809	0.659	1.273
	Other depressive disorders (eg, dysthymia)	43.7	495,951	44.9	9,399	39.5	63,253	33.2	14,263	41.5	11,589	1.028	0.903	0.759	0.949
	PTSD	41.8	473,699	30.2	6,323	24.7	39,653	25.4	10,937	34.8	9,717	0.724	0.592	0.609	0.833
	Anxiety disorder	26.1	296,466	26.0	5,447	19.8	31,672	18.8	8,070	25.9	7,238	0.996	0.756	0.718	0.992
	Adjustment disorder	10.2	115,639	13.4	2,805	13.5	21,685	12.2	5,245	10.0	2,787	1.315	1.327	1.197	0.979
	Personality disorder	2.7	30,676	6.1	1,283	5.9	9,442	5.5	2,375	11.5	3,226	2.268	2.179	2.043	4.271
	Other psychiatric diagnosis	18.8	213,714	21.5	4,506	20.2	32,454	19.2	8,269	26.4	7,367	1.143	1.075	1.021	1.400
	Dual diagnosis	19.0	215,937	39.2	8,191	44.8	71,813	38.4	16,527	43.9	12,251	2.057	2.354	2.020	2.304
Substance Use Disorder
	Any substance use disorder	9.9	112,789	28.3	5,917	35.5	56,838	29.5	12,662	33.5	9,347	2.845	3.567	2.963	3.366
	Alcohol	13.8	156,291	29.5	6,173	33.9	54,290	30.1	12,938	31.3	8,732	2.142	2.459	2.185	2.269
	Cannabis	3.8	42,884	9.8	2,057	11.9	19,030	10.1	4,348	12.1	3,378	2.601	3.141	2.676	3.199
	Cocaine	2.5	28,593	12.3	2,565	17.7	28,334	13.1	5,610	15.0	4,201	4.864	7.014	5.178	5.967
	Opioid	3.9	44,190	13.0	2,716	17.2	27,577	15.8	6,797	15.9	4,436	3.333	4.417	4.059	4.077
	Sedative/hypnotic	0.5	5,127	1.2	241	1.4	2,278	1.5	625	1.5	431	2.549	3.145	3.217	3.414
	Amphetamine	0.5	5,969	1.7	352	2.6	4,246	2.9	1,244	2.2	627	3.198	5.035	5.500	4.266

(1) Non-substantial differences involving less than 5% of the sample are notshown. Data available on request.

Table 3. Bivariate comparison of service utilization and psychotropic prescription fills among veterans in community care treatment and mental health clinics only.

		Mental Health Clinic (1)		Vocational (2)		Homelessness (3)		Criminal Justice (4)		SMI Services (5)		2 vs 1	3 vs 1	4 vs 1	5 vs 1
	N=	1,134,377		20,921		160,273		42,985		27,931		Effect Size
		Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Cohen d
General psychiatry visits		5.81	9.27	15.96	22.89	16.51	24.43	11.83	22.54	67.37	74.42	0.602	0.634	0.357	3.650
General psychiatry visits excluding communtiy-based programs		5.81	9.27	10.60	20.01	8.04	19.65	6.00	16.69	15.98	28.61	0.389	0.181	0.016	0.826
Substance abuse clinic visits		0.90	7.91	7.76	25.47	8.08	26.01	8.31	24.94	7.17	25.34	0.515	0.539	0.556	0.471
Medical surgical visits		9.60	11.12	10.66	11.40	10.07	11.76	9.54	12.27	13.45	14.53	0.092	0.040	-0.006	0.334
	Primary care visits	3.43	3.50	4.02	3.86	3.93	4.24	3.27	3.96	4.71	5.08	0.156	0.134	-0.044	0.344
	Speciality medical clinic visits	6.17	9.35	6.64	9.40	6.14	9.52	6.26	10.16	8.74	12.12	0.049	-0.003	0.010	0.267
Emergency room visits		0.60	1.58	1.06	2.32	1.37	2.97	1.22	2.67	1.87	4.13	0.232	0.388	0.313	0.644
		%	N	%	N	%	N	%	N	%	N	Risk Ratio
Any mental health inpatient treatment		2.8	32,134	8.0	1,674	10.3	16,581	9.4	4,029	25.2	7,037	2.825	3.652	3.309	8.894
Any medical surgical inpatient treatment		7.9	90,143	8.7	1,814	11.6	18,563	12.0	5,154	14.3	4,007	1.091	1.458	1.509	1.805
Psychotropic medication prescriptions		Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Cohen d
	Antidepressant prescriptions	5.67	9.79	6.45	16.22	5.84	13.63	5.26	13.52	12.37	25.31	0.069	0.015	-0.037	0.595
	Antipsychotic prescriptions	1.76	8.09	2.65	11.73	2.53	10.53	2.06	9.29	16.41	35.24	0.089	0.077	0.030	1.467
	Anxiolytic/sedative/hypnotic prescriptions	2.90	5.64	2.29	6.57	1.92	5.71	1.78	5.33	4.77	9.73	-0.104	-0.167	-0.192	0.318
	Stimulant prescriptions	0.16	1.28	0.20	3.52	0.10	1.74	0.10	1.38	0.13	1.32	0.024	-0.042	-0.042	-0.024
	Anticonvulsant/Mood Stabilizer Prescriptions	1.55	6.09	2.08	8.64	2.19	9.04	2.04	9.04	7.12	21.19	0.072	0.087	0.067	0.756
	Lithium prescriptions	0.13	1.65	0.25	2.51	0.21	2.51	0.18	2.18	1.47	9.95	0.052	0.033	0.022	0.577
	All Psychotropics	13.03	21.03	14.74	33.21	14.40	30.33	13.85	30.64	43.05	70.05	0.068	0.054	0.033	1.189
	Opiate Prescriptions	7.51	7.50	6.72	7.70	7.20	8.32	6.81	8.61	7.49	9.38	-0.101	-0.040	-0.090	-0.002
Intensive community treatment programs		Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Cohen d
	SMI Services	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	46.58	67.38	n/a	n/a	n/a	n/a
	Criminal justice outreach, jail diversion visits	0.00	0.00	0.00	0.00	0.00	0.00	2.45	4.27	0.19	1.64	n/a	n/a	n/a	n/a
	Homelessness visits	0.00	0.00	0.00	0.00	7.49	10.95	2.70	8.45	3.30	10.08	n/a	n/a	n/a	n/a
	Vocational rehabilitation visits	0.00	0.00	5.36	9.63	1.54	5.93	1.03	5.05	1.56	6.08	n/a	n/a	n/a	n/a
	Total intensive community treatment visits	0.00	0.00	5.36	9.63	9.04	13.41	6.18	12.46	51.63	68.38	n/a	n/a	n/a	n/a

Table 4. Multinomial logistic regression with multimorbidity characteristics, comparing veterans treated in community psychiatry care with those in mental health.

		Vocational		Homeless		Criminal Justice		SMI Services
		OR	Standardized Regression coefficient	OR	Standardized Regression coefficient	OR	Standardized Regression coefficient	OR	Standardized Regression coefficient
Demographics
	Age	0.977	-0.191**	0.993	-0.0574**	0.991	-0.075**	1.002	0.015**
	Income	1.000	-0.200**	1.000	-0.413**	1.000	-0.040**	1.000	-0.062**
	Black race	2.040	0.156**	2.570	0.206**	1.422	0.077**	1.799	0.128**
	Small rural area residence	0.638	-0.068**	0.509	-0.102**	0.836	-0.027**	0.513	-0.100**
	Isolated rural area residence	0.635	-0.059**	0.478	-0.097**	0.896	-0.015**	0.406	-0.118**
	Pension	1.142	0.014*	1.614	0.050**	1.018	0.002**	2.480	0.095**
	Service connected 50% or more	0.466	-0.202**	0.394	-0.246**	0.493	-0.187**	1.279	0.065**
Diagnoses
	Connective tissue disease	0.822	-0.011	0.772	-0.014**	1.018	0.001**	0.643	-0.024**
	Hepatic disease	1.207	0.021**	1.255	0.025**	1.014	0.002**	1.070	0.0070
	Human immunodeficiency virus	1.480	0.018**	1.268	0.011**	1.011	0.001**	1.075	0.0030
	Dementia	0.233	-0.094**	0.304	-0.077**	0.868	-0.009**	0.709	-0.022**
Multi-morbidity
	Number of psychiatric diagnoses	1.004	0.003	0.840	-0.115**	0.714	-0.222**	1.482	0.260**
	Number of substance use disorder diagnoses	1.666	0.217**	1.953	0.285**	2.025	0.300**	1.663	0.217**
Service Use
	General psychiatry visits excluding communtiy-based programs	1.019	0.130**	1.015	0.106**	1.009	0.062**	1.018	0.126**
	Substance abuse clinic visits	1.018	0.132**	1.016	0.118**	1.019	0.141**	1.013	0.097**
	Medical surgical clinic visits	1.012	0.076**	1.006	0.036**	1.008	0.048**	1.007	0.047**
	Emergency room visits	1.065	0.070**	1.105	0.111**	1.107	0.113**	1.073	0.078**
	Any mental health inpatient treatment	1.446	0.043**	2.138	0.089**	2.516	0.108**	3.267	0.139**
	Any medical surgical inpatient treatment	0.850	-0.026**	1.081	0.013**	1.270	0.038**	0.899	-0.017**
	All psychotropic medications	1.001	0.017*	1.000	-0.004	0.998	-0.033**	1.007	0.100**

*p<.01, **p<.0001

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Social Determinants of Mental Health Care Systems: Intensive Community Based Care in The Veterans Health Administration

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