Measuring Need for Public Mental Health Services: Building a Measure of Unmet Need in State Mental Health Systems

1. Measuring Need for Public Mental Health Services: Building a Measure of Unmet Need in State Mental Health Systems Ted Lutterman National Association of State Mental Health Program Directors Research Institute National Data Infrastructure Grant Meeting October 3-4, 2002 Washington, DC

2. Unmet Need and the DIGs/URS • URS Table 1: Estimated Number of Adults with Serious Mental Illness and Children with Serious Emotional Disturbances • Data Provided by CMHS using Federal Definitions • Adult SMI Population estimated at 5.4% • Children’s SED Population Estimated at 7 to 13%

3. Unmet Need and the DIGs/URS • URS Table 2: Profile of Persons Served By State Mental Health Agency Systems • Unduplicated count of persons served by State MH Systems • Focus is all served, not just SMI • Count clients when they receive any service, not just clients who received all “needed” services • Data Depicted by Age by Gender by Race/Ethnicity

4. Unmet Need and the DIGs/URS • URS Developmental Table 13: Profile of Unmet Needs of the State Population • Data to be provided by CMHS using Federal Definitions • Estimates for Adults Serious Mental Illnesses (SMI) • Estimates for Children with Serious Emotional Disorders (SED) • Methodology for Measuring Unmet Need not yet finalized

5. Unmet Need and the DIGs/URS • URS Developmental Table 14: Profile of Persons with SMI/SED Served By State Mental Health Agency Systems • Unduplicated count of persons served by State MH Systems • Focus is adults with SMI and Children with SED • Uses the Federal Definition of SMI • Issue of how to operationalize the federal definition in states • Data Depicted by Age by Gender by Race/Ethnicity

6. Unmet Need and the DIGs/URS • What Unmet Need is NOT: • Table 1 Prevalence minus Table 14 SMI Served by the SMHA System • E.g., if Table 1 says a state has 200,000 people with SMI and Table 14 shows a SMHA System served 75,000 adults with SMI, then Unmet need is NOT 200,000 – 75,000 = 125,000

7. Why Prevalence minus SMHA Served is not Unmet Need • Many people receive MH services in other settings: • Private MH Providers • General Medical Providers • Other State Agencies • Education, Child Welfare, Juvenile Justice, Public Health, Corrections, Welfare, etc. • Peer and Other Self Help Settings • Just Because a Person Received a Service and was counted in Table 2 or Table 14, doesn’t mean their need for services was met

8. Surgeon General’s Report: Where People Receive MH/AOD Services Percent of Adult Population Using MH/Addictive Services in One Year

9. Estimating Unmet Need • Combination of both Epidemiological Data on the Prevalence of Mental Illness in the population: Prevalence in terms of both diagnoses and functional impairments • Combined with: • Data on clients receiving mental health services • In Public MH systems • In Private MH Systems • In General Health System • In Other Human Service Systems • Data on the Types and Intensities of Services that Consumers Need

11. Epidemiological Data on Mental Health: • Two major national studies: • Epidemiological Catchments Area (ECA) studies conducted in 5 Cities by NIMH in the early 1980s. • 20,000 people surveyed • Adults age 18 and older • One Month, six-month, and lifetime prevalence rates • National Co-morbidity Study (NCS) conducted in 1990-1992 by Dr. Kessler, et.al. • Nationally representative, face-to-face household survey • Persons aged 15 to 54 years • 12 Month prevalence rates • National Co-morbidity Study Replication (NCS-R) • Replication of NCS conducted in 1999-2001 • Results from NCS-R will be out in 2003

12. Population of US with any Mental Illness 2/2002 Article by William Narrow, MD, et.al, Revised the Prevalence Estimates of Mental Health Disorders in the US by factoring in “Clinical Significance” criteria from DSM-IV. Result is a decrease in Prevalence Estimates to 18.5% for persons over age 18

13. National Epidemiological Data • Prevalence Rates: Adults: • 5.4% of adult population have SMI (Federal Definition) • 2.6% have Severe and/or Persistent Mental Illness(SPMI) • Served in the Public System: 16 State Study: 0.8% to 3.2% of State Population

14. Population of US with any Mental Illness and with a Serious Mental Illness

15. Adults with Serious Mental Illness who Received Any MH Services 46.5% of the 5.4% with SMI received services: therefore 2.5% of the adult population has an SMI and receives MH Services

16. Population of US with any Mental Illness and with a Serious Mental Illness Who Received Treatment

18. Adults with Serious Mental Illness Who Did Not Receive Any MH Services • Some will have health insurance and be able to access private services • Need to determine which adults who didn’t receive services will likely need public services • NCS data suggest that persons with lower income were less likely to access MH services • One option to identify persons likely to need publicly funded services being used by some states is to use income levels • 150%, 200% or 300% of poverty level as likely to need publicly funded MH services

19. Adults with Serious Mental Illness Didn’t Receive Any MH Services

20. Adults with Serious Mental Illness Didn’t Receive Any MH Services • The estimate of the number of persons who need publicly funded services is an estimate of Untreated Prevalence, not Unmet Need • Need to know what types, intensities, and durations of services they are likely to need to treat their illnesses

21. Adults with Serious Mental Illness who Received Any MH Services • Adults with mental illnesses and SMI are served in a variety of settings • Just because a person received MH Services does not mean their MH needs were met • Only one service contact is needed to be counted as served…this does not mean needs were met • NCS Suggests persons served in the general medical sector were less likely to receive appropriate care • MH clients may be receiving certain MH services because they are available, not because they are appropriate

22. Adults with Serious Mental Illness who Received Any MH Services

23. Adults with Serious Mental Illness who Received Any MH Services • For each area providing mental health services, some assessment of what types of services clients receive, and what they need to receive are needed to assess “adequacy of treatment”

24. Adults with Serious Mental Illness who Received Any MH Services

25. Number of Adults with a SMI who need specific MH Services • Alternative to the top down approach to building estimates from national prevalence data, is the building of estimates of need up from specific services • Focus on evidence-based services and other essential mental health services identified by states • Look at specifics of service: who needs this service?, at what level?, and for how long?

26. Number of Adults with a SMI who need specific MH Services Assertive Community Treatment (ACT) example • How many clients are likely to need ACT? • What are their diagnostic, functional, and income characteristics that predict need for publicly funded ACT services • How many ACT services will they need? • What duration of services • What intensity of services

27. Number of Adults with SMI Needing Specific Services and Amount of Services Needed

28. Number of Adults with a SMI who need specific MH Services • Number of people and services needed for individual services can be aggregated to develop systems level estimates of service needs • Build interactions between services into models: If more ACT services are provided, does the needed number of hospital beds decrease?

29. Measuring Unmet Need • Number Needing Appropriate Mental Health Services: • Appropriate Services are: • Number Needing Appropriate Services = • Number Not Receiving Any Mental Health + • Number Receiving MH Services that Don’t Meet Needs