The State of Mental Health in Guilford County

A presentation to the Moses Cone-Wesley Long

Community Health FoundationApril 29, 2010

Kelly N. Graves, PhDAnne Buford, MPA, NCC, LPCSonja Frison, PhD, MPHAmanda Ireland, MATerri L. Shelton, PhD

AcknowledgementsErin BalkindAnderson BeanKorinne ChiuFrederick DouglasKelley RichardsonMegan SmellClaretta WitherspoonAll the youth, families, providers, and agencies

that assisted or participated in surveys and focus groups

Mental Health as a PriorityOne of the nation’s top public health prioritiesHealthy 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

Methodological ApproachReview of national, state, and local data/trends

Including preliminary examination of resources/gaps

Implementation of participatory action research framework:Six focus groupsNine key informant interviewsOnline community survey, conducted through

snowball sampling (N = 206)Feedback from community forums

Scope of the ProblemAccording 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 unemployedAccording 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

DSM-IV Diagnosis % Identified – Guilford LME % Identified - Statewide

Attention deficit disorder 46% 53%Oppositional defiant disorder 31% 33%

Adjustment disorder(s) 17% 16%Severity of Mental Health Symptoms, Past Month % Identified – Guilford LME % Identified - Statewide

None or mild 12% 16%Moderate 60% 54%

Severe or very severe 27% 30%Behavior Symptoms and Abuse, Past 3 Months % Identified – Guilford LME % Identified - Statewide

Suicide attempts 2% 2%Suicidal thoughts 8% 13%

Attempted self-injury 6% 9%Physical injury to another person 48% 58%

Physically abused 29% 36%Problem Interference with School/Daily Activities % Identified – Guilford LME % Identified - Statewide

None 5% 5%A few times 46% 44%

More than a few times 48% 50%

Quality of Life Rating% Identified “Fair” or “Poor”

– Guilford LME% Identified “Fair” or “Poor”

- StatewidePhysical health 22% 21%

Emotional well-being 80% 76%Family relationships 72% 65%

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

Guilford LME – Quality Management Team, NCDMHDDSAS

DSM-IV Diagnosis % Identified – Guilford LME % Identified - StatewideAttention deficit disorder 35% 34%

Oppositional defiant disorder 39% 41%Conduct disorder 19% 15%

Severity of Mental Health Symptoms, Past Month % Identified – Guilford LME % Identified – StatewideNone or mild 25% 24%

Moderate 46% 50%Severe or very severe 28% 26%

Behavior Symptoms and Abuse % Identified – Guilford LME % Identified – StatewideSuicide attempts in lifetime 11% 10%

Suicidal thoughts in past 3 months 14% 18%Attempted self-injury/Self-injury 49% 45%Physical injury to another person 9% 11%

Physically abused in past 3 months 30% 29%Problem Interference with Work/School/Daily Activities,

Past 3 Months% Identified – Guilford LME % Identified – Statewide



Quality of Life Rating% Identified “Fair” or “Poor” –

Guilford LME% Identified “Fair” or “Poor” –

StatewidePhysical health 24% 24%


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


DSM-IV Diagnosis % Identified – Guilford LME % Identified - StatewideMajor depression 34% 42%

Schizophrenia 23% 21%Bipolar disorder 24% 24%

Severity of Mental Health Symptoms, Past Month % Identified – Guilford LME % Identified – StatewideNone or mild 13% 14%

Moderate 49% 44%Severe or very severe 38% 41%

Behavior Symptoms and Violence % Identified – Guilford LME % Identified – StatewideSuicide attempts in lifetime 28% 35%

Suicidal thoughts 32% 37%Attempted self-injury 9% 12%

Physical injury to another person 17% 13%Physical violence in past 3 months 15% 12%

Problem Interference with Work/School/Daily Activities,

Past 3 Months% Identified – Guilford LME % Identified – Statewide



Quality of Life Rating% Identified “Fair” or “Poor”

– Guilford LME% Identified “Fair” or “Poor”

– StatewidePhysical health 66% 65%


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


Health DisparitiesSocioeconomic Level – Serious psychological stress and

poverty

Race/ethnicity – Prevalence - 30% more often among African American

adults than non-Hispanic White adultsSymptoms - 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%)

Special PopulationsCo-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 useGuilford County 2008 – 966 girls between 15-19

years (3 teens each day)

Special PopulationsImmigrant 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 manyAll 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

Special PopulationsHIV/AIDS – majority have 2 or more

psychiatric diagnoses, 81% report substance useImpacts medication adherence and increased

risk for suicidal behaviorsElderly – 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

NC’s Report CardNational 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).

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

Treated PrevalenceTreated prevalence rates for persons with mental

illness vary widelyTreated prevalence = persons estimated to have

mental health conditions needing services who actually receive services for their mental health conditions

Quality Management Team, NCDMHDDSAS, 2010

Clinical Population Estimated

to be in Need

Persons Served Percentage

ServedGuilford

Percentage Served State

Adults with MH 19,728 8,929 45% 48%

Children/Adolescents with MH 11,135 4,871 44% 49%

Costs of Mental IllnessCosts 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.

Costs of Mental IllnessAccording to the NC State Center for Health

Statistics:3,377 persons in NC died due to a mental health or

substance abuse diagnosis in 20071,093 persons in NC died due to suicide in 2007$530 million were spent in NC in 2007 for inpatient

hospitalizationsAccording 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

Costs of Mental IllnessIn 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 2008-2009Akland & Akland, 2008; Guilford Center, 2009; Budget and Finance Team, NCDMHDDSAS, n.d.;Quality Management Team, NCDMHDDSAS, 2010

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 CenterSpecialized mental health services from Tristan’s Quest, Youth

Focus, Youth Villages, Therapeutic AlternativesResidential/independent life skills services from My Sister

Susan’s House, Destiny House, Sanctuary House, Joseph’s House, Shepherd House

What were community perceptions on the following:

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

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

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

Support Programs that Demonstrate Both Evidence-Based Practice and Practice-Based Evidence

Foundation Action: Prioritize programs that include:

1) Cognitive-Behavioral Frameworks2) Motivational Interviewing (MI) Techniques3) 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.

Foundation Action: Prioritize programs that include:

1) Cognitive-Behavioral Frameworks2) Motivational Interviewing (MI) Techniques3) 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.

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.

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.

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.

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.

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 settingsSupport 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.

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 settingsSupport 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.

Increase Attention to Special Populations

Foundation Action: Support programs targeting immigrant, homeless, and non-English speaking populationsIncrease funding for interpreter training

Interpreter Access Project (http://cnnc.uncg.edu/programs/iap/iaptraining.htm).

Raise awareness and advocate for Title VI compliance among providersSupport continuing education opportunities in the interpreting professionSupport 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.

Foundation Action: Support programs targeting immigrant, homeless, and non-English speaking populationsIncrease funding for interpreter training

Interpreter Access Project (http://cnnc.uncg.edu/programs/iap/iaptraining.htm).

Raise awareness and advocate for Title VI compliance among providersSupport continuing education opportunities in the interpreting professionSupport 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.

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.

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.

Policy Implications

Foundation Action:Require funded direct service programs to have a supplemental or sliding fee scaleFund programs implementing EBPs for a minimum of three yearsFavor EBP implementation programs that include regularly tracked performance measures coupled with client incentivesSupport 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

Foundation Action:Require funded direct service programs to have a supplemental or sliding fee scaleFund programs implementing EBPs for a minimum of three yearsFavor EBP implementation programs that include regularly tracked performance measures coupled with client incentivesSupport 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

ConclusionsNationally identified public health priorityFundamental to physical health and quality of

lifeMoving toward parityLocal community priority

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

Questions and

Comments

Contact InformationDr. Kelly Graves: [email protected] Buford: [email protected]. Sonja Frison: [email protected] Ireland: [email protected]. Terri Shelton: [email protected]

330 S. Greene StreetSuite 200Greensboro, NC 27401336-217-9713

The State of Mental Health in Guilford County

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