摘要：Objectives. We examined associations between patient characteristics and self-reported difficulties in accessing mental health and general medical care services. Methods. Patients were recruited from the Continuous Improvement for Veterans in Care–Mood Disorders study. We used multivariable logistic regression analyses to assess whether predisposing (demographic characteristics), enabling (e.g., homelessness), or need (bipolar symptoms, substance abuse) factors were associated with difficulties in obtaining care, difficulties in locating specialty providers, and forgoing care because of cost. Results. Patients reported greater difficulty in accessing general medical services than in accessing psychiatric care. Individuals experiencing bipolar symptoms more frequently avoided psychiatric care because of cost (odds ratio [OR] = 2.43) and perceived greater difficulties in accessing medical specialists (OR = 2.06). Homeless individuals were more likely to report hospitalization barriers, whereas older and minority patients generally encountered fewer problems accessing treatment. Conclusions. Need and enabling factors were most influential in predicting self-reported difficulties in accessing care, subsequently interfering with treatment dynamics and jeopardizing clinical outcomes. Efforts in the Department of Veterans Affairs to expand mental health care access should be coupled with efforts to ensure adequate access to general medical services among patients with chronic mental illnesses. Bipolar disorder is a chronic mental illness associated with substantial functional impairment, health care costs, and premature mortality. 1 , 2 Patients afflicted with this psychiatric disorder, which is uniquely characterized by alternating periods of mania, psychosis, and depression, require intensive pharmacological and psychosocial management. 3 , 4 Nearly 70% of the costs associated with treating bipolar disorder are attributable to disproportionately high prevalence rates of co-occurring general medical disorders, foremost including hypertension, alcohol abuse, and diabetes. 5 , 6 The individual and societal costs of the illness may be considerably underestimated given the related social and occupational instability, stigma, and caregiver burden. 7 Unfortunately, recent evidence suggests that patients with bipolar disorder and other serious mental illnesses have substantial unmet medical needs or fail to obtain necessary procedures. 8 , 9 However, little research has explored how these patients, whose treatment is managed primarily within mental health specialty clinics, perceive their level of access to appropriate care for general medical conditions. Despite the availability of effective therapies, bipolar disorder is often inadequately treated because of other neglected medical conditions along with financial, cultural, or other barriers. 10 Limited access, coupled with poor adherence to treatment, 11 results in a downward-spiraling obstacle to appropriate care through disruptions in regular treatment, deteriorating symptoms, and numerous adverse clinical events. Past examinations have shown that a variety of factors play a role in the access problems experienced by patients with serious mental illnesses, including demographic characteristics, social support, homelessness, comorbidities or illness severity, behavioral and lifestyle choices, cultural values regarding mental illness, health beliefs, and perceptions about treatment convenience or availability. 12 – 16 Yet, few studies have quantified the effects of these potential barriers to mental health and general medical care, and, until recently, most research efforts focused on schizophrenia rather than bipolar disorder. 17 , 18 Health service researchers, medical sociologists, and policy evaluators have used several conceptual models to frame the issue of treatment access and potential barriers. In their seminal work, Penchansky and Thomas described the 5 “A's” of access—affordability, acceptability, accommodation, accessibility (geographic), and availability—to illustrate dimensions of the overall fit between patients and providers. 19 Accessibility and availability are especially relevant in maintaining longitudinal treatment retention among patients with serious mental illnesses, an essential link between access and subsequent outcomes. 20 Becker's Health Belief Model incorporated attitudes about disease susceptibility and treatment benefits, a theoretical foundation frequently employed in access studies. 21 The Institute of Medicine defined access itself as a formal benchmark outcome for health organizations, particularly with respect to members of ethnic minority groups and other patients at risk of encountering access barriers. 22 Numerous factors influence objective measurements of health care use as well as individual perceptions of access to health care services. In recognition of the complex interplay of patient factors and health beliefs, we employed another conceptual framework, the Andersen–Aday Behavioral Model of Health Care Use, 23 in our study. In the Andersen–Aday model, patient characteristics are categorized into 3 domains, beginning with predisposing factors , which are most commonly demographic characteristics or other fixed characteristics. Second, enabling factors , i.e., variables that can assist or motivate a patient to seek treatment, including social support, insurance coverage, and a regular source of care, are identified. Finally, need factors , which represent dimensions such as illness severity and the extent of comorbid psychiatric or medical conditions, are defined. The Andersen–Aday model also recognizes that nonpatient influences, such as health system or environmental factors, are potentially associated with outcomes. When the model was adapted to vulnerable homeless patients, variables were expanded to include ability to navigate a health system and the notion of balancing competing health care demands. 24 Used in studies of various health conditions and populations, 25 – 27 the Andersen–Aday model is applicable to health service use, treatment adherence, and potential access problems. Enabling factors generally account for the majority of access problems experienced by patients, although demographic characteristics and need factors also play significant roles in determining access among patients with psychiatric conditions. 28 The prevalence of bipolar disorder in the United States has remained stable at approximately 1% to 2% over the past 2 decades, 29 , 30 although inclusion of the clinically important bipolar disorder spectrum pushes this rate up to 6%. 31 More significant, there was a 56% increase in the number of patients hospitalized with a primary diagnosis of bipolar disorder from 1996 to 2004, 32 with attitudes toward seeking mental health care substantially improving over time. 33 These trends support the importance of reducing access barriers to psychiatric and medical care across all health care systems. The Veterans Health Administration (part of the Department of Veterans Affairs [VA]) provided care to nearly 80 000 veterans with bipolar disorder in 2004, up nearly 40% from 1999. 34 The VA, the nation's largest integrated health care system, offers preferential care to disadvantaged patients, and traditionally access and treatment cost barriers have been less restrictive in general than in other health systems. The deinstitutionalization efforts of the mid-1990s greatly expanded outpatient treatment sites, 35 widely considered successful in increasing access to essential care. 36 , 37 As such, the VA can be viewed as a natural laboratory for studies pertaining to access. A recent article documented increasing rates of psychiatric disorders among Iraq veterans, patients also suffering from serious physical ailments. 38 Although providing timely access to mental health treatment in primary care settings remains a high VA priority, ensuring appropriate general medical care for a rapidly growing cohort of veterans with chronic mental illnesses is a major emerging issue. Our primary objectives here were to examine self-reported access barriers to mental health and general medical care among patients with bipolar disorder and to explore patient factors associated with these perceptions.
