AssessingAdultMentalHealthNeedsInCA Chis

6/18/2012 Mental Health Services Oversight and Accountability Commission Meeting Assessing Adult Mental Health Needs in California: Using the California Health Interview Survey (CHIS) SSe rgii o AAg uiill ar-GGaxiiolla , MM DD, PPhhDD Professor of Clinical Internal Medicine Director, Center for Reducing Health Disparities Sacramento, CA July 28, 2011 1 AAsssseessssiinngg AAdduulltt MMeennttaall HHeeaalltthh NNeeeeddss iinn CCaalliiffoorrnniiaa:: UUssiinngg tthhee CCaalliiffoorrnniiaa HHeeaalltthh IInntteerrvviieeww SSuurrvveeyy ((CCHHIISS)) • RReeppoorrtt pprreeppaarreedd ffoorr tthhee MMeennttaall HHeeaalltthh SSeerrvviicceess Oversight and Accountability Commission (MHSOAC) • Based on a contract with the UC Davis Center for Reducing Health Disparities • Prepared in collaboration with the California Health IInntteerrvviieeww SSuurrvveeyy DDiirreeccttoorr aanndd ssttaaffff , UUCCLLAA CCeenntteerr ffoorr Health Policy Research 2 1 6/18/2012 SSeevveerree PPssyycchhoollooggiiccaall DDiissttrreessss ((SSPPDD)) • SPD is based on the Kessler-6 • Series of questions about the frequency of feelings over o the past 30 days (SPD 30-day) o the worst month in the past year (SPD 12-mos) • Individual items are scored to provide an index, with range (0, 24) with K6 > 13 indicating SPD • SPD provides a robust estimate of the population with severe mentt all iilllln ess ((SSMMII)) wiitthhiin a populla ttii on • Is a non-specific, general indicator of psychological distress 3 Source: Grant,, 2011 Six Items in KKeesssslleerr 66 ((KK66)), Adults 18 and over, K6 > 13, N = 4,010, CHIS 2007 In the past 12 months, about All of Most of Some of A little Not at how often did you…… the time the time the time of the all time %% %% %% %% %% Feel nervous 30.8 42.6 19.9 4.4 2.3 Feel hopeless 22.0 39.8 30.7 5.9 1.6 Feel restless 30.1 35.2 25.7 6.5 2.6 Feel depressed 19.4 35.9 34.8 7.3 2.6 Feel everything is an effort 31.3 38.1 24.0 4.8 1.8 Feel worthless 17.0 26.6 34.4 12.0 10.0 4 Source: Grant, Padilla-Frausto, Aydin, Streja, Aguilar-Gaxiola, Caldwell, 2011 2 6/18/2012 Conceptual Model for Assessing Mental Health Need in CA: CHIS 2007 All Adults N = 26,769,450 No Psychological Distress Serious Psychological Distress (K6 < 13) (K6 > 13) DSTRS12 = 2 DSTRS12 = 1 N = 24,482,848 N = 2,286,602 **No Mental Health Need** At least Moderate impairment in at No Impairment least ONE Domain (IMPAIR2 < 1) (IMPAIR2 > 1) N = 62,202 N = 2,224,400 **Serious Psychological Distress, no **Mental Health Need** impairment ** Source: CHIS 2007 5 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 Level of impairment from SShheeeehhaann DDiissaabbiilliittyy SSccaallee, Adults 18 and over, K6 score > 13, N = 4,010, CHIS 2007 Did your emotions interfere a lot, some, Severe Moderate No or not at all with your… (a lot) (some) Impairment (not at all) % % % Performance at work* 44.0 37.1 18.8 Household chores 49.5 33.4 17.0 Social life 57.6 32.0 10.5 RRellattiionshhiip wiitthh ffamiilly andd ffriiendds 4488 .66 3399 .33 1122 .11 *Note: Performance at work is only asked of adults, age 18 – 70. 6 Source: Grant, Padilla-Frausto, Aydin, Streja, Aguilar-Gaxiola, Caldwell, 2011 3 6/18/2012 Conceptual Model for Assessing Mental Health Need in CA: CHIS 2007 All Adults N = 26,769,450 No Psychological Distress Serious Psychological Distress (K6 < 13) (K6 > 13) DSTRS12 = 2 DSTRS12 = 1 N = 24,482,848 N = 2,286,602 **No Mental Health Need** At least Moderate impairment in at No Impairment least ONE Domain (IMPAIR2 < 1) (IMPAIR2 >1) N = 62,202 N = 2,224,400 **Serious Psychological Distress, no **Mental Health Need** impairment ** Source: CHIS 2007 7 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 Rates of Mental Health Need by Poverty Level, CHIS 2007* 11.3% 0‐99% FPL 10.6% 100‐199% 200‐299% 9.7% Statewide 8.3% > 300% 6.5% *I ACdojunsfitdeedn fcoer Iangteer avnald sex Source: CHIS 2007 8 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 4 6/18/2012 Rates of Mental Health Need by Insurance Type, CHIS 2007* 10.0% Public (Non Medicare) 10% Uninsured Statewide 8.3% Medicare Private 7.8% 7.0% I Confidence Interval * Adjusted for age and sex Source: CHIS 2007 9 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 Rates of Mental Health Need by Race/Ethnicity, CHIS 2007* American Indian/ Alaskan Native 15.3% Other 12.6% African American 9.2% White 8.5% 8.3% Latino 8.3% Statewide 5.6% Asian Only I Confidence Interval * ASdojuursctee:d C fHoIrS a 2g0e0 a7nd sex 10 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 5 6/18/2012 Rates of Mental Health Need by Nativity Status for Latino and Asian, CHIS 2007* 10.8% U.S. Born Latino 8.3% Statewide Latino Born Abroad 6.7% Asian Born Abroad 5.7% U.S. Born Asian 3.7% I Confidence Interval * Adjusted for age and sex Source: CHIS 2007 11 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 LLaanngguuaaggeess SSppookkeenn iinn HHHH AAmmoonngg SSPPDD 1122--mmooss,, CCHHIISS 22000077 Spanish only Asian 3 oonnllyy 6 English & Asian 7% 19 64% English & English Spanish only Source: CHIS 2007 12 Source: Grant, 2011 6 6/18/2012 Mental Health Need and Co-morbidity 13 Rates of Current Smokers and Binge Drinkers by Mental Health Need, CHIS 2007* 35 30 25 20 15 30.1% 29.3% 24.3% 10 1133 .00%% 5 0 Smokers w MHN Smokers wo MHN Binge Drinkers w MHN Binge Drinkers wo MHN I Confidence Interval * Adjusted for age and sex Source: CHIS 2007 14 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 7 6/18/2012 MMeennttaall HHeeaalltthh TTrreeaattmmeenntt MMeeaassuurreess 15 MMeennttaall HHeeaalltthh TTrreeaattmmeenntt MMeeaassuurreess (((( RRxx)))) 16 8 6/18/2012 MMeennttaall HHeeaalltthh TTrreeaattmmeenntt FFiinnddiinnggss • Among those identified as having a mental health nneeeedd,, aabboouutt hhaallff ((4499..66%%)) rreeppoorrtteedd tthhaatt tthheeyy rreecceeiivveedd treatment by either a primary care physician or mental health professional, while the other half (50.4%) reported that they did not receive needed treatment. 17 Mental Health Need by Treatment Source, CHIS 2007* 60 50 40 17.2% 30 43.9% 20 32.2% 10 6.7% 0 AAn y TTr eattm entt ((PPCCPP or MMentta ll HHealltthh NNo TTr eattm entt Professional) Daily Rx No Daily Rx I Confidence Interval * Adjusted for age and sex Source: CHIS 2007 18 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 9 6/18/2012 DDiissccuussssiioonn ooff CCHHIISS MMeennttaall HHeeaalltthh FFiinnddiinnggss • Findings are preliminary and need further analysis • In California, mental health status (as measured by SPD) differs by age, gender, income, insurance, and race/ethnicity and nativity, and other factors … but o Serious psychological distress (PSD) is in large part a ffuunnccttiioonn ooff eeccoonnoommiicc ppoossiittiioonn • Latino immigrants • Single parents with children o Economic status is important, but just one of many factors associated with mental health outcomes 19 Source: Modified from Grant, 2011 MMeennttaall HHeeaalltthh NNeeeedd • The concept of need is fundamental to understanding, planning and tracking mental health services in California. • Those with a “mental health need” are those with serious psychological distress (K6 > 13) and at least a moderate level of impairment in one or more domains (SDS > 1). • Those without a mental health need are all others who do not meet this threshold of combined symptoms and impairment 20 10 6/18/2012 Prevalence of Mental Health Need by Race/Ethnicity, Adults 18 and over, CHIS 2007 30% 25% 20% 15% 10% 8.3% 16.7% 14.9% 12.3% 13.0% 5% 9.0% 7.9% 8.0% 10.6% 9.6% 8.5% 66.00%% 66..99%% 0% Latino White African American American Indian/Alaskan Asian Native Hawaiian/ I Confidence Interval Native Pa M cif u ic lt i I - s R la a n c d ia e l rs/ Unadjusted Adjusted (Age, Gender, Income, Education) All Adults, California Source: CHIS 2007 21 Source: Grant, Padilla-Frausto, Aydin, Streja, Aguilar-Gaxiola, Caldwell, 2011 Prevalence of Mental Health Need by Nativity Status for Latino and Asian, Adults 18 and over, CHIS 2007 16% 14% 12% 10% 8.3% 8% 6% 11.7% 9.7% 44%% 6.9% 6.5% 6.4% 6.8% 5.8% 6.2% 2% 0% US Born Latino Latino Born Abroad US Born Asian Asian Born Abroad I SCoounrfcidee: nCceH IInSt e2r0va0l7 Unadjusted Adjusted (Age, Gender, Income, Education) All Adults, California 22 Source: Grant, Padilla-Frausto, Aydin, Streja, Aguilar-Gaxiola, Caldwell, 2011 11 6/18/2012 MMeett aanndd UUnnmmeett NNeeeedd • Met need is defined as the proportion of people with a disorder who see a health professional. • The concept of unmet need is of critical importance in assessing whether or not people with mental health needs are accessing and receiving adequate mental health services. • Unmet need is the proportion of people who meet a threshold for problems with their mental health, emotions, nerves, or use of alcohol or drugs and did not received minimally adequate treatment (MAT). 23 Source: Andrews, 2000; Grant, Padilla-Frausto, Aydin, Streja, Aguilar-Gaxiola, Caldwell, 2011 MMiinniimmaallllyy AAddeeqquuaattee TTrreeaattmmeenntt ((MMAATT)) • Minimally Adequate Treatment (MAT) is based on evidence-based guidelines for the treatment of a serious mental illness (SMI). • Evidence-based MAT includes either 1) four or more visits with a health professional and at least two months of prescribed medication, or 2) eight visits of psychotherapy lasting at least tthhiirrttyy mmiinnuutteess.. • CHIS doesn’t capture the duration of prescription medication use nor the duration of psychotherapy sessions. 24 Source: Grant, Padilla-Frausto, Aydin, Streja, Aguilar-Gaxiola, Caldwell, 2011 12 6/18/2012 MMeett aanndd UUnnmmeett NNeeeedd Mental Health Treatment Met Unmet Unmet Need t t deeN htlaeH Met Need Need 25 latneM Un-Need Met Un-Need Unmet Un-Need DDiissccuussssiioonn ((22)) • Improving mental health in California’s increasingly diverse population will require diverse approaches andd serii ous consiidde ratii on off ff actors suchh as: o Language o Culture o Stigma and discrimination o Health insurance coverage o Comprehensive resources to address economic and other sources of stressors: • Job training • Housing • Parenting and childcare resources • Other 26 Source: Modified from Grant, 2011 13 6/18/2012 DDiissccuussssiioonn aanndd RReeccoommmmeennddaattiioonn • MHSA and healthcare reform provide new opportunities to address and improve mental health services and outtcomes, andd tto ddo so more effffiic iienttlly • Data and evidence can and should be part of the decision-making process o CHIS o DMH and Medi-Cal administrative data o County data (CSI) o Hospitalization and law enforcement data o California Behavioral Health Services Needs Assessment 27 Source: Modified from Grant, 2011; BHSNA, 2011 Recommendations for an Enhanced CHIS Mental Health Survey Purpose: to obtain an accurate “Baseline” assessment ooff mmeennttaall hheeaalltthh sseerrvviicceess nneeeedd aanndd ttrreeaattmmeenntt uuttiilliizzaattiioonn in California. 1. Incorporate a follow-back study to validate the estimates of SMI/SPD and calibrate the cut point of the K-6 in a state-wide population (rather than the national population). aa. TToo bbee ddoonnee wwiitthh aa rraannddoomm ssaammppllee ooff CCHHIISS rreessppoonnddeennttss who scored moderate to high on the K6 scale (SPD) using a diagnostic interview tool like the WHO-CIDI. 28 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 14 6/18/2012 Recommendations for an Enhanced CHIS Mental Health Survey (2) 2. Increase the CHIS sample size for low-income persons by oversampling households with incomes below 200% off tthhe ffe dde rall povertty lle vell. a. A subset of randomly selected telephone numbers (stratified by region, gender, age, and race/ethnicity) from the Medi-Cal database would also be included in the enhanced survey. 3. Increase CHIS sample size for key subpopulations such as diverse race/ethnicity/nativity subpopulations, the iinnssttiittuuttiioonnaalliizzeedd, tthhee hhoommeelleessss , eettcc . CCHHIISS iiss aa hhoouusseehhoolldd survey and does not capture the prevalence of mental health needs among those who live in group quarters (e.g. nursing homes, dormitories, residential treatment centers, prisons, etc.), or homeless. 29 Source: Padilla-Frausto, Grant, Aguilar-Gaxiola, 2011 CCoonncclluussiioonn • California policy makers, decision makers, consumers and their families, providers, researchers need to know: o Who needs ((pprreevvaalleennccee)) and receives ((ccuurrrreenntt uusseerrss)) services? o How much of this need is met ((mmeett nneeeedd)) and how much need is unmet ((uunnmmeett nneeeedd))? o What are the gaps? What changes will the health system need to implement in order ttoo iimmpprroovvee aacccceessss ttoo and tthhee qquuaalliittyy aanndd eeffffeeccttiivveenneessss ooff ccaarree? • What should the service population look like? 30 Source: Modified from BHSNA Work Plan, 2011 15 6/18/2012 Acknowledgements David Grant, Ph.D. Imelda Padilla-Frausto,, MPH May Aydin, Ph.D. Leanne Streja, PhD Julia Caldwell, MPH Estelle Geraghty, MD, MS, MPH/CPH Marbella Sala UC Davis, Center for Reducing Health Disparities 31 16