National Association of State Head National Association of State Head Injury Administrators (NASHIA) Injury Administrators (NASHIA)

Public Policy SymposiumPublic Policy Symposium

Robert W. Glover, Ph.D.Executive DirectorNational Association of State Mental Health Program Directors

March 26, 2009

Headlines: Why Mental Health Should Be Part of

Health Reform

Summary SlideSummary Slide

Who Are We?Who Are We? Who Do We Serve?Who Do We Serve? Where Do We Serve Them?Where Do We Serve Them? What is the Link Between Mental What is the Link Between Mental

Health and Health?Health and Health?– SmokingSmoking– ObesityObesity– Suicide PreventionSuicide Prevention– Returning VeteransReturning Veterans

NASMHPD

Represents the $29.5 Billion Public Mental Health System serving 6.1 million people annually in all 50 states, 4 territories, and the District of Columbia.

An affiliation with the approximately 220 State Psychiatric Hospitals: Serve 200,000 people per year and 50,000 people served at any point in time.

6.1 Million Persons Served by 6.1 Million Persons Served by SMHA Systems: 2006SMHA Systems: 2006

96% were served in the Community96% were served in the Community– 3.1% served in state psychiatric hospitals3.1% served in state psychiatric hospitals

22% were Employed22% were Employed– 48% were not in Labor Force48% were not in Labor Force

79% lived in Private Residences79% lived in Private Residences– 2.9% were homeless2.9% were homeless

71% reported positive outcomes from their services71% reported positive outcomes from their services 62% had some Medicaid coverage for their Mental 62% had some Medicaid coverage for their Mental

health serviceshealth services– 38% had No Medicaid Coverage38% had No Medicaid Coverage

2006 URS Reporting2006 URS Reporting

History of State History of State HospitalsHospitals

In 1954 there were:In 1954 there were:– 352 state hospitals352 state hospitals– 553,979 Residents in SH at the end of the year553,979 Residents in SH at the end of the year– 178,003 Admissions during the year178,003 Admissions during the year– 42,652 Deaths in state hospitals during the year 42,652 Deaths in state hospitals during the year

(Peaked in 1958 at 51,383 deaths)(Peaked in 1958 at 51,383 deaths)

In 2007In 2007::– 228 state hospitals (2007 NRI State Profiles)228 state hospitals (2007 NRI State Profiles)– 49,000 Residents (2007 NRI State Profiles)49,000 Residents (2007 NRI State Profiles)– 174,013 Admissions during the year (2006 URS)174,013 Admissions during the year (2006 URS)– Deaths: not reportedDeaths: not reported

Source: CMHS Uniform Reporting System, 2006

Number of Psychiatric Beds, By Number of Psychiatric Beds, By Type of Hospital and Year, U.S. Type of Hospital and Year, U.S. 1970 to 20021970 to 2002

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

1970 1976 1980 1985 1990 1995 1998 2000 2002

State Hospitals

Private PsychiatricHospitalsVA PsychiatricServicesGeneral Hospitals

Source: Mental Health United States, 2004

Psychiatric Beds as a Percent of Total Hospital Beds in the US, 1970 to 2002

33%

20%

14%

0%

5%

10%

15%

20%

25%

30%

35%

1970 1986 2002

In 1970, 1 out of 3 hospital

beds in America was a

psychiatric bed

In 2002, 1 out of 7 hospital beds in America was a psychiatric bed

Source: NIMH and NRI

State Mental Health Agency Controlled Expenditures for State Mental Health Agency Controlled Expenditures for State Psychiatric Hospital Inpatient and Community-State Psychiatric Hospital Inpatient and Community-Based Services as a Percent of Total Expenditures: FY'81 Based Services as a Percent of Total Expenditures: FY'81 to FY'05to FY'05

State Hospital Inpatient

27%

Community

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

USA TodayFront Page

Thursday,

May 3, 2007

People with Serious Mental People with Serious Mental Illness Experience 25 Years Illness Experience 25 Years Lost Life: A Public Health Lost Life: A Public Health CrisisCrisis

SmokingSmoking ObesityObesity SuicideSuicide

Substance AbuseSubstance Abuse Inadequate Inadequate

Medical CareMedical Care

People reporting a mental disorder in the past month consumed approximately 44.3% of all cigarettes smoked in the U.S.

Lasser, Karen; Boyd, J. Wesley; Woolhandler, Steffie; Himmelstein, David U.; McCormick, Danny; Bor, David H., "Smoking and mental illness: A population-based

prevalence study." JAMA, The Journal of the American Medical Association. Nov 22-29, 2000, 284, (20), 2606 - 2610.

A Free sample background from www.awesomebackgrounds.com

© 2002 By Default!Slide 14

Rates of smoking are Rates of smoking are 2-2-4 times4 times higher among higher among people people with with psychiatricpsychiatricdisorders disorders and and substance substance use use disorders.disorders.

Kalman D, Morissette SB, George TP. American Journal on Addictions. 2005, 106-123.Kalman D, Morissette SB, George TP. American Journal on Addictions. 2005, 106-123.

Major depression 50 to 60 % Anxiety disorder 45

to 60 % Bipolar disorder 55

to 70 % Schizophrenia 65

to 85 %

Presentation at the NASMHPD Medical Directors Council Technical Report Meeting on Smoking Policy and Treatment at State Operated Psychiatric Hospitals, April

20-21, 2006, San Francisco, California. * DeLeon et al., in press.

Smoking Prevalence among Smoking Prevalence among People with Mental Illnesses:People with Mental Illnesses:

* 20% of those with schizophrenia started smoking at college age and many began smoking in mental health settings receiving cigarettes for good behavior.

Rates of smoking among treatment staff in mental health and substance abuse facilities and programs are higher than other health care professionals:

NASMHPD Research Institute, Inc. (2006). Survey on Smoking Policies and Practices for Psychiatric Facilities.*** Strouse R, Hall J and Kovac M. Survey of Health Professionals' Knowledge, Attitudes, Beliefs, and Behaviors

Regarding Smoking Cessation Assistance and Counseling. Princeton, N.J.: Mathematica Policy Research, Inc., 2004, 1-16.

30%-35% of Mental 30%-35% of Mental Health Providers SmokeHealth Providers Smoke

Primary Care Physicians 1.7 %

Emergency Physicians 5.7 %

Psychiatrists 3.2 % Registered Nurses 13.1

%Dentists

5.8 %Dental Hygienists 5.4 %Pharmacists 4.5 %

***

Obesity, Metabolic Obesity, Metabolic Syndrome, and Syndrome, and

Diabetes EpidemicDiabetes Epidemic

No Data Less than 4% 4% to 6% Above 6%

Mokdad et al. Diabetes Care. 2000;23:1278-1283.

Diabetes and Gestational Diabetes Trends: Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 1990US Adults, BRFSS 1990

Mokdad et al. JAMA. 2001;286(10).

Diabetes and Gestational Diabetes Diabetes and Gestational Diabetes Trends: Trends:

US Adults, BRFSS 2000US Adults, BRFSS 2000

No Data Less than 4% 4% to 6% Above 6%

www.diabetes.org.

No Data Less than 4% 4% to 6% Above 6% Above 10%

Diabetes and Gestational Diabetes Diabetes and Gestational Diabetes Trends: Trends:

US Adults, Estimate for 2010US Adults, Estimate for 2010

Suicide PreventionSuicide Prevention Suicide is the leading cause of violent Suicide is the leading cause of violent

deaths worldwidedeaths worldwide In the United StatesIn the United States

– Number of deaths by suicide in 2004: Number of deaths by suicide in 2004: 32,43932,439 (CDC WISQARS website and “Fatal Injury Reports”: (CDC WISQARS website and “Fatal Injury Reports”: http://www.cdc.gov/ncipc/wisqars)http://www.cdc.gov/ncipc/wisqars)

– Deaths per 100,000 population: Deaths per 100,000 population: 11.111.1– An average of 1 person every 16.2 An average of 1 person every 16.2

minutes died by suicide.minutes died by suicide.– Many of them preventable through timely Many of them preventable through timely

intervention.intervention. National Suicide Prevention Lifeline: National Suicide Prevention Lifeline:

1-800-273-TALK1-800-273-TALK

*Press 1 for Veterans Services

Mental Illnesses are Chronic Mental Illnesses are Chronic Illnesses that Impose Great Costs on Illnesses that Impose Great Costs on

Our SocietyOur Society In 2002, mental illnesses contributed to In 2002, mental illnesses contributed to $193 billion$193 billion

in lost productivity in lost productivity • More than the revenue of 499 of the Fortune 500 companiesMore than the revenue of 499 of the Fortune 500 companies• By 2013, this figure is estimated to rise to more than By 2013, this figure is estimated to rise to more than $300 $300

billionbillion. .

The World Health Organization has found that The World Health Organization has found that depression was the depression was the fourthfourth leading cause of disease- leading cause of disease-burden in 1990 and by 2020 will be the burden in 1990 and by 2020 will be the singlesingle leading cause. leading cause.

Indeed, mental illness is already the Indeed, mental illness is already the leadingleading cause cause of disability for people between 15 and 44 in the of disability for people between 15 and 44 in the United States and Canada. United States and Canada.

Mental Illnesses are Chronic Illnesses that Impose Great Costs

on Our Society (Cont)

Data from the Agency for Healthcare Data from the Agency for Healthcare Research and Quality (AHRQ) shows that Research and Quality (AHRQ) shows that expenditures for adults with a specific expenditures for adults with a specific chronic condition AND a mental health chronic condition AND a mental health condition greatly exceed expenditures for condition greatly exceed expenditures for those without a mental health conditionthose without a mental health condition

Annual Medical Expenditures for Adults with a Specific Chronic Condition, with and without a Mental Health

Condition

 Cost without mental health condition

Cost with mental health condition

All adults * $1,913 $3,545

Heart condition

4,697 6,919

High blood pressure

3,481 5,492

Asthma 2,908 4,028

Diabetes 4,172 5,559*-Refers to all adults with and without chronic conditions.

Information from U.S. Department of Health and Human Services. The 2002 and 2003 MEPS. AHRQ, Rockville, Md.

People with Serious Mental People with Serious Mental Illness Experience 25 Years Illness Experience 25 Years Lost LifeLost Life

People with schizophrenia die People with schizophrenia die from diabetes at from diabetes at 2.7 2.7 times the times the rate of the general populationrate of the general population– 2.3 2.3 times the rate from times the rate from

cardiovascular diseasecardiovascular disease– 3.23.2 times the rate from respiratory times the rate from respiratory

diseasedisease– 3.43.4 times the rate from infectious times the rate from infectious

diseases. diseases.

Depression and Other Depression and Other ConditionsConditions The likelihood of heart attack is The likelihood of heart attack is

fourfour times greater for persons times greater for persons with depression than in general with depression than in general population; the likelihood of population; the likelihood of stroke is stroke is 2.62.6 times greater. times greater.

Inadequate Healthcare Inadequate Healthcare and Insuranceand Insurance

Many people with mental health suffer Many people with mental health suffer from chronic conditions simply because from chronic conditions simply because they are not receiving appropriate they are not receiving appropriate healthcare. healthcare.

People with mental illnesses are People with mental illnesses are uninsured at twice the rate of the uninsured at twice the rate of the general population: general population: 34%34% of people with of people with mental illness have no health coverage mental illness have no health coverage at this point. at this point.

In other words, many people with In other words, many people with mental illnesses are excluded from our mental illnesses are excluded from our nation’s porous healthcare system right nation’s porous healthcare system right from the start. from the start.

Mental Health Is Essential to Health:Mental Health Is Essential to Health:

Need for Prevention ApproachNeed for Prevention Approach We must also approach prevention We must also approach prevention

across the lifespan and work to provide across the lifespan and work to provide the appropriate screens, starting with the appropriate screens, starting with well-child visits that can identify the co-well-child visits that can identify the co-occurrence of mental health and chronic occurrence of mental health and chronic conditions. conditions.

It has long been a popular belief that It has long been a popular belief that mental illnesses begin in late mental illnesses begin in late adolescence or early adulthood. In fact, adolescence or early adulthood. In fact, this is a misconception. this is a misconception. The average The average age of onset for mental disorders is 14. age of onset for mental disorders is 14.

Role of TraumaRole of Trauma

We must develop a better understanding We must develop a better understanding of role trauma plays in mental health of role trauma plays in mental health conditions and then employ approaches conditions and then employ approaches that mitigate trauma’s effect. that mitigate trauma’s effect.

We must understand and address We must understand and address maternal depression, the consequences maternal depression, the consequences it can have on a young child’s physical it can have on a young child’s physical and emotional development, and the and emotional development, and the ways it can play out over the span of that ways it can play out over the span of that young child’s life. young child’s life.

Returning VeteransReturning Veterans

Center for the Study of Traumatic Stress

I would be seen as weak

My unit leadershipmight treat me differently

Members of my unit might haveless confidence in me

It would harm my career

My leaders would blame mefor the problem

*Participants were asked to “rate each of the possible concerns that might affect your decision to receive mental health counseling or services if you ever had a problem.”Hoge CW, et al. N Engl J Med. 2004;351:13-22.

Barriers to Care and Mental Health Risk*

24

20

31

33

31

50

51

59

63

65

0 10 20 30 40 50 60 70 80

Agree or Strongly Agree, %

Screen posScreen neg

Provided byRobert Ursano, M.D.

Center for the Study of Traumatic Stress

I don’t have adequate transportation

I don’t trustmental health professionals

I don’t know whereto get help

There would be difficulty getting time off work for treatment

It is difficult toschedule an appointment

Barriers to Care and Mental Health Risk*

(cont’d)

*Participants were asked to “rate each of the possible concerns that might affect your decision to receive mental health counseling or services if you ever had a problem.”Hoge CW, et al. N Engl J Med. 2004;351:13-22.

6

6

17

22

38

18

22

45

55

17

0 10 20 30 40 50 60 70 80

Screen posScreen neg

Agree or Strongly Agree, %Provided byRobert Ursano, M.D.

Center for the Study of Traumatic Stress

How many Americans have returned from Iraq or Afghanistan?

1.6 Million ** Figure does not count contractors

If it were evenly distributed that would be 30,000 per state.

If all were combat exposed that might be 6000 cases of PTSD/Depression per state.

If ¼ combat then 1500 cases PTSD and TBI (1/6 combat exposed with TBI) 1250 cases TBI per state.

Provided byRobert Ursano, M.D.

NASMHPD President’s Task Force on NASMHPD President’s Task Force on Returning VeteransReturning Veterans

Charge:Charge: To address issues related to the provision To address issues related to the provision of mental health services provided to veterans of mental health services provided to veterans (and their families) returning home from Iraq and (and their families) returning home from Iraq and Afghanistan.Afghanistan.

Survey of States’ ServicesSurvey of States’ Services

MembersMembersCommissionersCommissioners Nancy Rollins (New Hampshire)…ChairNancy Rollins (New Hampshire)…Chair Linda Roebuck (New Mexico)Linda Roebuck (New Mexico) Mike Lancaster (North Carolina)Mike Lancaster (North Carolina) Terri White (Oklahoma)Terri White (Oklahoma)Medical DirectorsMedical Directors Alan Radke (Minnesota)Alan Radke (Minnesota) Jim Evans (Virginia)Jim Evans (Virginia)Division RepresentDivision Representativeative Joan Smyrski (Maine)Joan Smyrski (Maine)

Returning Veterans Returning Veterans NASMHPD InitiativesNASMHPD Initiatives

Addressing Issue at NASMHPD Addressing Issue at NASMHPD Commissioner Meetings (Winter Commissioner Meetings (Winter 2007, Winter 2008, Summer 2007, Winter 2008, Summer 2009)2009)

Veterans Administration on Veterans Administration on Suicide Prevention and Potential Suicide Prevention and Potential PartneringPartnering

SAMHSA Grant Announcement on SAMHSA Grant Announcement on Jail Diversion and Trauma – Jail Diversion and Trauma – Priority VeteransPriority Veterans

Thank You!Thank You!