The State of Mental Health in Guilford County

1. The State of Mental Healthin Guilford County A presentation to the Moses Cone-Wesley Long Community Health Foundation April 29, 2010 Kelly N. Graves, PhD Anne Buford, MPA, NCC, LPC Sonja Frison, PhD, MPH Amanda Ireland, MA Terri L. Shelton, PhD

2. Acknowledgements • Erin Balkind • Anderson Bean • Korinne Chiu • Frederick Douglas • Kelley Richardson • Megan Smell • Claretta Witherspoon • All the youth, families, providers, and agencies that assisted or participated in surveys and focus groups

3. Mental Health as a Priority • One of the nation’s top public health priorities • Healthy People 2010 and 2020 mental health-related goals: • Increase treatment access and engagement among various populations • Reduce suicide attempts and completions • Utilize consumer satisfaction measures • Increase mental health services and referrals at primary care locations • The World Health Organization (WHO, 2001, p. 1) noted that “mental health is as important as physical health to the overall well-being of individuals, societies and countries.” • Mental health is connected to physical health, quality of life, community well-being • Important to treat mental illness and promote mental health • Mental health as a continuum Herrman, Saxena, Moodie, & Walker, 2005; Keyes, 2007; U.S. DHHS, 2000, 2001, 2009

4. Methodological Approach • Review of national, state, and local data/trends • Including preliminary examination of resources/gaps • Implementation of participatory action research framework: • Six focus groups • Nine key informant interviews • Online community survey, conducted through snowball sampling (N = 206) • Feedback from community forums

6. Scope of the Problem • According to the 2008 National Survey on Drug Use and Health: • Approximately 10 million adults in U.S. experienced serious mental illness in previous year (4.4% of adult population) • Highest rates among those 18-25 years old, women, persons of more than one race, the unemployed • According to averages of the 2005 and 2006 National Survey on Drug Use and Health: • Approximately 743,000 adults in NC experienced serious psychological distress in previous year (11.6% of adult population) • Approximately 474,000 adults in NC experienced at least one major depressive episode in previous year (7.4% of adult population) • Approximately 60,000 children/adolescents in NC experienced at least one major depressive episode in previous year (8.4% of child/adolescent population) Hughes, Sathe, & Spagnola, 2008; SAMHSA Office of Applied Studies, 2009

7. Selected Results from NC-TOPPS Initial Interviews: July 2008 – June 2009 Child Mental Health Consumers, Ages 6 to 11 (N=366; 61% Male, 39% Female) Guilford LME – Quality Management Team, NCDMHDDSAS

8. Selected Results from NC-TOPPS Initial Interviews: July 2008 – June 2009 Adolescent Mental Health Consumers, Ages 12 to 17 (N=595; 59% male, 41% female) Guilford LME – Quality Management Team, NCDMHDDSAS

9. Selected Results from NC-TOPPS Initial Interviews: July 2008 – June 2009 Adult Mental Health Consumers, Ages 18 and Older (N=903; 42% male, 58% female) Guilford LME – Quality Management Team, NCDMHDDSAS

10. Health Disparities • Socioeconomic Level – Serious psychological stress and poverty • Race/ethnicity – • Prevalence - 30% more often among African American adults than non-Hispanic White adults • Symptoms - Suicide attempt rates found to be almost twice as high among Hispanic adolescents (grades 9-12) as compared to non-Hispanic White adolescents • Access / Receipt of Services - Non-Hispanic White adults more often connected with mental health services (14%) than non-Hispanic Black adults (7.4%), Hispanic adults (7.0%), American Indian/Alaskan Native adults (10.7%), and Asian American adults (5.6%)

11. Special Populations • Co-Occurring Disorders – estimates range widely in NC from 2%-68% • Homeless individuals – between 20%-40% are both mentally ill and without a home (1.4 million people in US) • Point in time counts of homeless in Guilford – 1,064 (23% are children) • Adolescent parents – 57% report mental health symptoms, increased substance use • Guilford County 2008 – 966 girls between 15-19 years (3 teens each day)

12. Special Populations • Immigrant Populations – estimates vary widely, but access, language and culture, and stigma prevent treatment in many cases • Adult and juvenile justice – estimates vary widely (40%-90%), higher for females • “criminalization of the mentally ill” • College Populations – First time seeking services and diagnosis for many • All eight colleges and universities have a counseling center and/or offer some counseling services for students, with at least crisis intervention, assessment, and/or short term counseling

13. Special Populations • HIV/AIDS – majority have 2 or more psychiatric diagnoses, 81% report substance use • Impacts medication adherence and increased risk for suicidal behaviors • Elderly – 22% of population • Older, Caucasian males have highest rates of suicide in US • Reductions in social contact, self-worth, and pain and frustration around physical illness

14. NC’s Report Card • National Alliance on Mental Illness (NAMI) – Grading the States: A Report on America’s Health Care System for Adults with Serious Mental Illness • 2006 – NC received a grade of D+. Evaluation elements included: infrastructure (C-); information access (D); services (D); and recovery supports (B+) • 2009 – NC received a grade of D. Evaluation elements included: health promotion/measurement (D); financing and core treatment/recovery services (C); consumer/family empowerment (F); and community integration/ social inclusion (C).

15. http://www.nami.org/gtsTemplate09.cfm?Section=Grading_the_States_2009http://www.nami.org/gtsTemplate09.cfm?Section=Grading_the_States_2009

16. Treated Prevalence • Treated prevalence rates for persons with mental illness vary widely • Treated prevalence = persons estimated to have mental health conditions needing services who actually receive services for their mental health conditions Quality Management Team, NCDMHDDSAS, 2010

17. Costs of Mental Illness • Costs are direct and indirect. They include: • Treatment, disability, unemployment, incarceration, homelessness, substance abuse, suicide • According to the 2009 Medical Expenditure Panel Survey: • Mental disorders accounted for greatest rise in medical expenses between 1996 and 2006 (from $35.2 billion to $57.5 billion in adjusted figures) • Census of persons with mental health expense outlays grew from 19.3 million to 36.2 million across same time period • Researchers estimate roughly $193 billion in income lost each year due to mental illness (estimates were from early part of the decade; these may be underestimates by today’s costs) • Researchers link untreated mental illness to: • Chronic diseases, risky health-related behaviors, violence, work absenteeism AHRQ, 2009; CDC, n.d.; Kessler et al., 2008; NAMI, n.d.

18. Costs of Mental Illness • According to the NC State Center for Health Statistics: • 3,377 persons in NC died due to a mental health or substance abuse diagnosis in 2007 • 1,093 persons in NC died due to suicide in 2007 • $530 million were spent in NC in 2007 for inpatient hospitalizations • According to the NC Institute of Medicine: • Approximately 50,000 Disability-Adjusted Life Years were lost in NC in 2005 due to unipolar depression • In NC in 2006, per capita spending on mental health was one of the lowest (43rd) in the nation, at $16.80. Of that rate, the large majority goes to inpatient costs (65.5% compared to a 37.1% national average) Holmes, 2008; NC-CATCH Portal, n.d.; NC State Center for Health Statistics, 2009; Thompson & Broskowski, 2006

19. Costs of Mental Illness • In wake of mental health reform, researchers calculated: • A 21.9% increase in number of adult hospital admissions for Guilford Center LME, which went from 16,570 community hospital adult admission days in SFY 2005-2006 to 18,939 admission days in SFY 2006-2007 • A 32.1% increase in number of child hospital admissions for Guilford Center LME, which went from 2,005 community hospital child admission days in SFY 2005-2006 to 2,849 admission days in SFY 2006-2007 • According to NCDMHDDSAS: • For Q1 SFY 2009-2010, Guilford Center had 3rd highest LME ER admission rate for mental health diagnoses (153.9 per 10,000) • Guilford Center LME revenue and expenditures: • Increase of $3,143,503, or 9.4%, from SFY 2006-2007 to SFY 2008-2009 Akland & Akland, 2008; Guilford Center, 2009; Budget and Finance Team, NCDMHDDSAS, n.d.; Quality Management Team, NCDMHDDSAS, 2010

20. Listening to Community Voices

21. Faith community-provider collaborations, like Congregational Nurse Program • Emergency services at Guilford Center LME, Moses Cone Behavioral Health Center; mobile crisis care from Therapeutic Alternatives • Peer-led support groups/family support from Mental Health Associations in Greensboro and High Point, local NAMI chapter • Early-onset dementia support from Adult Center for Enrichment • Homeless support from Interactive Resource Center • Specialized mental health services from Tristan’s Quest, Youth Focus, Youth Villages, Therapeutic Alternatives • Residential/independent life skills services from My Sister Susan’s House, Destiny House, Sanctuary House, Joseph’s House, Shepherd House

22. What were community perceptions on the following:

23. Majority of survey respondents (73%) reported costs associated with mental health services as a barrier to accessing those services • Only 14.6% say mental health services affordable in Guilford • Fewest resources exist for: • Children under age 12, immigrant populations, non-English speaking populations, homeless persons

24. Providers and consumers noted needs for: • Coordination along continuum of care, step-down services, peer support, child/adolescent psychiatrists, respite care, intensive in-home services, specialized trauma services, home health evaluations for the elderly • Increasing understanding that mental illness and substance abuse often co-occur; addressing these issues in tandem

25. Barriers to Treatment (Community Feedback) • Difficulty navigating system, cost, waiting lists, transportation, mental health/physical symptoms, childcare needs, service locations • Examination of barriers and strategic planning to minimize these may lead to increased service utilization

26. Recommendations

27. Support Programs that Demonstrate Both Evidence-Based Practice and Practice-Based Evidence • Foundation Action: • Prioritize programs that include: • Cognitive-Behavioral Frameworks • Motivational Interviewing (MI) Techniques • 3) Consumer partnering • Support MI trainings within currently funded programs such as Congregational Nurses and Social Workers programs. • Support supervision trainings on a subset of evidence-based practice models • Potential Partners: Local provider networks, Guilford Center LME, NCDHHS MH/DD/SAS, and local colleges and universities to provide training and fidelity to evidence-based practice models.

28. Improve Access to Services • Foundation Action: • Support strategic planning, • Improvement of the available 1-800 access number • Education and awareness of the number through marketing and billboards throughout the community • Training of staff regarding services available • Consumer-friendly website • Search for providers on the web using specific search criteria to fit unique needs • Housed in a neutral, community-based agency such as NAMI, MHA in Greensboro or High Point, or Guilford CARES • Content available in print (as well as in multiple languages) and provided on a readable level to ensure health literacy • Distributed as collaborative resource guides across the county in a similar fashion to publications such as “Apartment Finders” • Potential Partners: Local provider networks, Guilford Center LME, MHA, NAMI, Guilford CARES.

29. Increase Awareness of Co-Occurring Mental Health and Substance Abuse as the Norm Rather than the Exception • Foundation Action: • Develop a Community Action Strategic Plan (CASP) • Support community dialogue • Build capacity to deliver integrated mental health/substance abuse treatment • Support Workforce Development Efforts • Training (In-service and AHEC) related to co-occurring disorders (e.g., educational, assessment, and treatment) • Special topics courses within local college and university graduate programs • Expanding the focus to include discussions regarding co-occurring disorders (modeled after local Say-It chapter) • Monthly provider meetings on evidence-best practices around co-occurring models and specific interventions. • Monitoring of implementation to ensure quality • Potential Partners: Community-based mental health and substance abuse agencies, local provider networks, Guilford Center LME, local and state consumer groups (NAMI, NCFU, Guilford CARES), peer-to-peer support, AHEC, local colleges and universities.

30. Co-Locate Mental Health Services • Foundation Action: • Support co-location of faith-based communities such as Congregational Nurses and Congregational Social Workers Programs. • Support programs that co-locate services in primary care settings • Support provision of co-located services in school settings • Mental health clinician in 2-3 schools. • Foundation can support situations in which provider cannot bill for services • Support training for staff and teachers about mental health signs and symptoms • Potential Partners: Local provider networks, Guilford Center LME, Guilford County Schools, primary care clinics, pediatricians, local colleges and universities.

31. Increase Attention to Special Populations • Foundation Action: • Support programs targeting immigrant, homeless, and non-English speaking populations • Increase funding for interpreter training • Interpreter Access Project (http://cnnc.uncg.edu/programs/iap/iaptraining.htm). • Raise awareness and advocate for Title VI compliance among providers • Support continuing education opportunities in the interpreting profession • Support translation of materials into next 2-3 most commonly occurring languages • Potential Partners: Local provider networks, Guilford Center LME, community-based organizations serving immigrant, homeless, and non-English speaking populations, interpreter training programs such as Center for New North Carolinians, AHEC, local colleges and universities.

32. Increase Attention to Service Gaps • Foundation Action: • Fund programs that address service gaps • availability of crisis beds, respite services, child/adolescent psychiatry services, peer-to-peer services, specialized trauma services (e.g., sexual assault support groups, returning military), wraparound and step-down services, and services to assist in the transition from adolescence to adulthood (i.e., emerging adulthood services). • Require funded programs to have a plan for addressing transportation issues if the program is not community-based or in-home • Potential Partners: Local provider networks, Guilford Center LME, community-based organizations, local and state consumer groups, local colleges and universities.

33. Policy Implications • Foundation Action: • Require funded direct service programs to have a supplemental or sliding fee scale • Fund programs implementing EBPs for a minimum of three years • Favor EBP implementation programs that include regularly tracked performance measures coupled with client incentives • Support a demonstration project that: • 1) addresses one of the identified service gaps AND; • 2) utilizes blended or braided funding • Potential Partners: Local provider networks, Guilford Center LME, community-based organizations, local colleges and universities, local foundations (e.g., Weaver Foundation, Cemala Foundation, Tannenbaum-Sternberger Foundation), Partners Ending Homelessness work group

34. Conclusions • Nationally identified public health priority • Fundamental to physical health and quality of life • Moving toward parity • Local community priority

35. People with mental problems are our neighbors. They are members of our congregations, members of our families; they are everywhere in this country. If we ignore their cries for help, we will be continuing to participate in the anguish from which those cries for help come. A problem of this magnitude will not go away. Because it will not go away…we are compelled to take action. ~Rosalynn Carter

36. Questions and Comments

37. Contact Information • Dr. Kelly Graves: kngrave3@uncg.edu • Anne Buford: apbuford@gmail.com • Dr. Sonja Frison: slfrison@uncg.edu • Amanda Ireland: mandyi05@gmail.com • Dr. Terri Shelton: shelton@uncg.edu 330 S. Greene Street Suite 200 Greensboro, NC 27401 336-217-9713