A Systematic Review of Health Outcomes Associated With Provision of Representative Payee Services

Five studies examined representative payee services’ association with housing stability (11–13, 27, 28). Representative payee services do not appear to decrease housing stability and may increase it. One study found that representative payee services were associated with fewer days of homelessness (27), another found a trend toward significance between representative payee services and fewer homeless days (12), and two studies did not find any association (11, 13). Rosenheck et al. (27) analyzed data from a study of assertive community treatment with 1,348 homeless individuals in 18 U.S. cities. They compared individuals who had a representative payee for the entire observation period, individuals who acquired a representative payee during the observation period, individuals who did not have a representative payee but who received public support, and individuals who did not have a representative payee and did not receive public support. They compared self-reported number of days literally homeless at baseline and at 3 months and calculated percentage change. Although all four groups reported fewer days of homelessness at 3 months, the two groups that received representative payee services for at least part of the observation period reported a greater decrease in days of homelessness, compared with the other two groups. The percentage change in homelessness days for the groups was as follows: newly acquired representative payee (N=140), –56%; continued representative payee services (N=115), –58%; public support only (N=623), –48%; and no public support (N=400), –51% (p=0.001).

Conrad et al. (12) studied 184 clients receiving care from the U.S. Department of Veterans Affairs (VA) who were randomly assigned to receive representative payee services through a community agency that coordinated services with the VA or who received general case management through the VA; the latter group could receive representative payee services through usual channels but not in a coordinated fashion. Participants were assessed at baseline and at 6 and 12 months. In the main analyses, the authors compared the experimental group (coordinated representative payee) to the control group (general case management). Individuals in the experimental group had 14.2 fewer days of homelessness (p=0.07) at 6 months and 10.9 fewer days (p=0.06) at 12 months, compared with the control group. However, not all participants in the experimental group received representative payee services; therefore, post hoc analyses compared individuals in the experimental group who received representative payee services, individuals in the experimental group who did not receive representative payee services, and individuals in the control group. At 12 months, those in the experimental group with representative payees had 14.9 fewer days of homelessness than those in the experimental group without a representative payee (p=0.08) and 21.2 fewer days of homelessness than those in the control group (p=0.02). Of note, however, some members of the control group also received representative payee services; therefore, post hoc results did not represent the independent effect of receiving representative payee services.

An analysis by Elbogen et al. (28) of baseline data from a cohort of 103 individuals with serious mental illness who were awaiting discharge from an inpatient setting before random assignment to a study arm showed that those who were receiving representative payee services had lower odds of reporting insufficient funds for housing, compared with those not receiving such services (odds ratio [OR]=.13, p<0.05).

Rosen et al. (11) analyzed data from the same intervention as Rosenheck et al. (27), looking at timing of representative payee enrollment. Specifically, the authors compared individuals who were not assigned a representative payee with those who were assigned a payee between months 0 and 3 and those who were assigned a payee between months 4 and 12. No differences between the groups were noted in number of days housed in the past 60 days. Similarly, an analysis by Ries and Comtois (13) of data from 275 individuals with serious mental illness and alcohol and other drug use who were receiving treatment services did not find a significant difference in housing stability measures between those who received representative payee services from the agency and those who did not.

Only one study found an association between representative payee services and symptoms of mental illness. Weiser et al. (29) analyzed one wave of data from a longitudinal study of 239 homeless or marginally housed men living with HIV in San Francisco. The authors found that those receiving representative payee services had higher rates of depressive symptoms on the Beck Depression Inventory, compared with those not receiving services, after adjustment for other covariates (adjusted OR=2.37, p<0.05). However, because the study was cross-sectional, there was no way to assess the direction of the association, because experiencing depressive symptoms may have increased the likelihood that a person would receive representative payee services in the first place.

Two studies examined changes in symptoms of mental illness (12, 27). Conrad et al. (12) assessed participant results on the Colorado Symptom Index (CSI) and found no significant difference in CSI change over time between the experimental and control groups or, in post hoc analyses, between the experimental group with a representative payee, the experimental group without a representative payee, and the control group. Rosenheck et al. (27) assessed the depression symptom score from the National Institute of Mental Health Diagnostic Interview Schedule, the psychosis symptom score from the Psychiatric Epidemiology Research Interview, and the Addiction Severity Index psychiatric composite score. No association was found between receipt of representative payee services and depression symptoms, psychosis symptoms, or addiction severity.

There is stronger evidence that receipt of representative payee services reduces inpatient utilization and increases outpatient utilization. Four studies examined mental health service utilization (10, 11, 13, 30). Luchins et al. (10) studied a cohort of 56 individuals with serious mental illness receiving services at an urban mental health center, including representative payee services, case management, and day treatment. The authors compared the 12 months preenrollment with the 12 months postenrollment and observed a reduction in the frequency of state hospitalizations (number reduced by 0.8, p<0.001) and duration of state hospitalizations (number of mean days reduced by 61.1, p<0.001) after receipt of services. Similar significant reductions were observed for a subsample of individuals for whom data were available on Medicaid-funded private hospitalizations. Even though Ries and Comtois (13) found that among individuals with serious mental illness and co-occurring substance use disorders, those who received representative payee services had higher illness severity than those who did not, the authors found no significant between-group difference in psychiatric hospitalization. Instead, individuals receiving representative payee services used significantly more hours of outpatient services than those without payee services, including case management (14.54 versus 6.27, respectively; p<0.002), group treatment (32.17 versus 15.93; p<0.002), and day treatment (13.26 versus 7.41; p<.05).

In post hoc analyses, Rosen et al. (11) found an increase in receipt of outpatient psychiatric services among individuals who acquired a representative payee in months 4–12, compared with other groups. Labrum (30) surveyed 573 U.S. adults who reported having a family member with a psychiatric disorder. Compared with individuals who received informal money management services from a family member (N=155), those with a family member who served as their representative payee (N=101) attended regular mental health treatment in higher proportions (78% of those with a representative payee versus 61% of those receiving informal money management services; p=0.005) and were more likely to have had a psychiatric hospitalization in the past year (57% versus 35%; p<0.001) (30). However, the data were cross-sectional, and the direction of the relationship between representative payee services and use of mental health care could not be distinguished.

Three of eight studies that examined the association of representative payee services and substance use found some significant relationships (12, 28, 31). Conrad et al. (12) reported that the experimental group (not all of whom received representative payee services) had significantly fewer drinks and drug months at 12 months, compared with the control group. Post hoc analyses showed that the experimental group that received representative payee services had significantly fewer drinks and drug months than the control group. Again, however, because some individuals in the control group may have also received representative payee services, the results did not represent the pure effect of having a representative payee. Elbogen et al. (28) found that individuals with serious mental illness receiving representative payee services had greater odds of comorbid substance abuse, compared with those not receiving payee services (OR=4.28, p<0.01), but the cross-sectional nature of the analysis limited interpretation of this association. Herbst et. al. (31) compared urine test results and clinic attendance days before and after receipt of an initial retroactive SSI or SSDI check for a group of 18 individuals receiving methadone treatment. Although no difference in positive urine screens was found in either group, those who did not receive representative payee services missed significantly more clinic days after check receipt (p=0.02). No other study reported significant differences between individuals receiving representative payee services and those who were not, regardless of the substance used or whether measures were self-reported (11, 27), clinician reported (11), reported by a family member (30), measured by urinalysis (32), or defined as drug treatment utilization (13).

Representative payee services may be associated with better quality of life. Conrad et al. (12) found that the experimental group rated their quality of life higher by an average of 0.5 points at 12-month follow-up, compared with the control group, on a single question with seven possible responses (“How do you feel about your life in general?”) (p<0.03). In post hoc analyses, the two experimental groups (with and without a representative payee) were not significantly different in quality-of-life ratings, but quality-of-life ratings of the experimental group with a representative payee were higher by 0.6 points than those of the control group (p=0.04). Again, however, the control group used in this study also included individuals with a representative payee.

Representative payee services may also be associated with mental health treatment adherence. Elbogen et al. (16) examined the impact of involuntary outpatient commitment (OPC), in which individuals with serious mental illness are mandated to receive community treatment to avoid hospitalization. Mental health treatment adherence, a composite variable computed as average frequency of adherence to all planned treatment (medication and scheduled visits with a mental health clinician) as reported by two interview sources, was assessed every 4 months over the course of 12 months. Compared with individuals who did not have a representative payee at any point in the 12 months, those who added a new representative payee during the year had 3.85-higher odds of better treatment adherence (p=0.003). Treatment adherence did not differ between those who had a representative payee all year or who terminated representative payee services during the year and those without a representative payee.

HIV viral suppression has been examined as an outcome. In a study of representative payee services offered as part of a supportive housing program to 18 people living with HIV, Hawk et al. (17) found that viral load suppression significantly decreased 6 months after enrollment in representative payee services. However, this was a pre-post study design without a control group.

Two studies looked at incarceration and arrest as outcomes. Ries and Comtois (13) examined differences in days incarcerated in the past 90 days between participants with and without a representative payee and found no significant difference between groups. Labrum (30) surveyed adults who served as a representative payee for a family member with a psychiatric disorder and compared them with adults who provided informal money management services and found no association between receipt of formal representative payee and arrest history in adulthood.

Two studies examined representative payee services’ effect on various aspects of the therapeutic relationship between the client and his or her provider and provided mixed evidence that representative payee services have an effect on the client-provider therapeutic relationship (13, 14). Angell et al. (14) surveyed 201 individuals receiving services in a large urban community mental health center that also offered representative payee services in which the mental health clinician had fiduciary authority. The client-provider relationship was compared between clients who had a clinician representative payee through the community mental health center and clients who had a noninstitutional representative payee (such as a family member) or clients without a representative payee. The authors looked at two subscales from the Working Relationship Scale: the client-provider bond subscale and the client-provider conflict subscale. Payee status was not associated with the client-provider bond. Having a clinician representative payee was associated with higher levels of client-provider conflict (p=0.04), but the experience of financial leverage (e.g., the client reported that the payee threatened to withhold or withheld money until the client complied with treatment) mediated the relationship between payee status and client-provider conflict. In addition, Ries and Comtois (13) assessed clients’ satisfaction with their case manager, treatment with respect and privacy, and condition and comfort of the building and found no significant differences between those with and without a representative payee.

Three studies examined the extent to which individuals with a representative payee reported experiencing financial leverage, and findings suggest that receipt of representative payee services is associated with financial leverage (14, 16, 33). Financial leverage was operationalized in various ways in each study but was generally defined as a representative payee’s use of control over an individual’s funds to encourage, incentivize, or otherwise coerce certain behaviors. In an analysis by Angell et al. (14) of individuals receiving mental health treatment and payee services in a community mental health clinic, financial leverage was defined as whether the client reported that the payee had ever withheld money until the client followed through on mental health treatment, alcohol or drug treatment, or medication adherence or whether in the past 6 months anyone had made the client feel as though he or she would not receive spending money if he or she did not attend treatment appointments or take medications. In bivariate analyses, having a clinician payee was associated with perceiving financial leverage (p<0.001). As discussed above, financial leverage mediated the relationship between payee status and client-provider conflict.

Elbogen et al. (16), in a study of individuals receiving OPC, used 12-month follow-up data to categorize participants into four groups: representative payee plus OPC, representative payee only, OPC only, and neither representative payee nor OPC. Financial leverage was assessed in three ways: an overall rating of perceived coercion as measured by the MacArthur Perceived Coercion Scale (self-reported by client), a single question about perceived coercion self-reported by the client (“Did you feel that if you did not keep your appointment at the mental health center or take your prescribed medications that someone would not give you your spending money?”), and a single question about “money warnings” asked of providers or family members (“Did you or anyone else tell the subject that if s/he did not keep her/his appointment at the mental health center that s/he would not get her/his spending money?”). An analysis found no significant differences between overall perceived coercion scores of those with only a representative payee or only OPC and those with neither a representative payee nor OPC (reference group); however, clients who had both a representative payee and OPC scored significantly higher (greater perceived coercion), compared with the reference group (OR=3.44, p=0.004). For the single question about perceived financial coercion, the group with only a representative payee (OR=3.59, p=0.003) and the group with both a representative payee and OPC (OR=3.82, p<0.001) had higher odds of reporting perceived coercion, compared with the reference group. Finally, clients with both a representative payee and OPC were significantly more likely than clients in the reference group to be given “money warnings” (OR=6.02, p=0.001), although no differences were found between those with a representative payee only or those with OPC only and the reference group.

Using only data from baseline assessments of the same sample, Elbogen et al. (33) reported results for 109 individuals who were receiving representative payee services at baseline and 149 who were not. The authors used the same single questions as above for perceived financial coercion and “money warnings.” In bivariate analyses, having a representative payee was associated with perceived financial coercion (48% of those with a representative payee perceived coercion versus 16% of those without a payee; p<0.001) and with receiving a money warning (24% of those with a representative payee got a warning versus 7% of those without a payee; p<0.001). In an adjusted regression model, having a representative payee remained associated with perceived coercion (OR=5.14, p<0.001) but not with receipt of a money warning.

Another outcome examined was money mismanagement (12, 34). Conrad et al. (12) used a 22-item Money Mismanagement Measure to assess money management skill change over time (a lower score indicated better money management). For the main analyses, on average, the experimental group had a 0.3-point lower score than the control group at 6 months (p=0.02) and 0.5-point lower score than the control group at 12 months (p<0.001). Post hoc analyses showed no difference in money mismanagement score change between the experimental groups with and without a representative payee; however, the experimental group with a representative payee had a 0.5-point lower score than the control group over the 12-month period (p=0.02). Moore et al. (34) analyzed baseline data of 107 participants in a randomized trial assessing a money management intervention. At baseline, those receiving representative payee services were no different than those not receiving such services in terms of self-reported money mismanagement.

Three studies looked at violence as an outcome of receipt of representative payee services (18, 35, 36). In another analysis of the sample of individuals randomly assigned to OPC, Elbogen et al. (18) divided the sample into two groups: those whose representative payee was a family member and those who received representative payee services from a nonfamily member or who did not receive representative payee services. At each time point, clients were asked whether they engaged in any physical fighting or actions causing bodily injury to a family member or whether they used a lethal weapon, such as a stick, club, blunt object, knife, sharp object, firearm, or explosive, to harm or threaten a family member in the previous 4 months. In bivariate and multivariable analyses, having a family representative payee was significantly associated with family violence (bivariate analysis: OR=1.93, p=0.05; multivariable analysis: OR=2.11, p=0.04). Additional analyses attempted to disentangle the amount of client contact with family (low versus high) from the relationship between having a family representative payee and violence. In multiple models that compared having a family representative payee plus high family contact with having a family representative payee plus low contact, with having no family representative payee plus high contact, and with having an family representative payee plus low contact, the results showed that having a family representative payee remained a significant predictor of family violence, regardless of the amount of client contact with the family.

Two cross-sectional studies also found an association between FRP and violence, using data from respondents to a survey of U.S. adults who reported having a relative with a psychiatric disorder (35, 36). Labrum and Solomon (35) estimated adjusted ORs for factors associated with experiencing family violence and constructed multivariate models for each independent variable, controlling for all other variables that were significantly associated with family violence. Family members who served as a representative payee had 2.93 higher odds of experiencing violence perpetrated by the person with a psychiatric disorder (p<0.001), compared with family members who did not serve as a representative payee. In a subsample of family members ages 55 and older (N=243), those who served as a representative payee to a family member with a psychiatric disorder had 2.76 higher odds (p=0.05) of experiencing financial abuse, compared with family members who did not serve as a representative payee. Financial abuse was assessed by the question, “In the past 6 months how many times has s/he [the relative with a psychiatric disorder] misused or stolen any of your funds, property, or assets?” No difference was found between groups in experiences of physical or psychological abuse (36).