Mental Health Status, Access to Care, and Service Utilization in

Mental Health Status, Access to Care, and Service Utilization in Ohio: Trends Related to Insurance, Income, Demographic Characteristics and Physical Health Research Conducted by

Background Mental Illness disproportionately affects vulnerable populations such as the uninsured, unemployed, disabled, and persons from diverse backgrounds. According to a 2006 Ohio Psychiatric Association report, more than 2 million children and adults are diagnosed with a mental disorder each year. The indirect costs of untreated mental health disorders (due to loss of productivity/ absenteeism) is estimated to be greater than 79 billion per year.

Background In general, studies show that health insurance and poverty status are strong determinants of access to mental health care. Even when insured, there is research to suggest that mental health needs may go untreated. A recent study by the National Center for Children in Poverty found that 79% of children with private health insurance had unmet mental health needs and 73% of children with public health insurance had unmet mental health needs.

Background Research also suggests a link between mental health, physical health and demographic factors. To support this idea, a longitudinal study of US Emergency Room Visits from 1992-2001 revealed that there were a reported 53 million mentalhealth related visits. A 2002 Mental Health Law Report found that lowincome children with mental health problems live with a parent that also suffers from poor mental health.

Background The Ohio Mental Health Parity Law calls for equal coverage for physical diseases and disorders and the diagnosis and treatment of biologically based mental illness (BBMI) However, the law does not apply to Medicaid or Medicare, and thus, a significant portion of Ohioans continue to have limited mental health care coverage. If Ohio is to move forward in decreasing the costs associated with mental illness, then it is imperative to better understand the complex relationships between insurance, demographics and mental health status.

Project Goals Summarize general mental health status and mental health insurance status (access to care) trends among children and adults in Ohio. Identify socio-economic and demographic trends related to poor mental health for children and adults in Ohio. Examine any co-morbidities between mental and physical health problems in children and adults.

Methods Descriptive analyses were conducted to achieve the project goals and increase understanding of mental health trends among children and adults in Ohio. Univariate and Multivariate analyses as appropriate to determine significance among variables. Respondents endorsing “Don’t Know” or “Refusal” were eliminated in the results presented in this report (except where noted).

Methods The following key questions were used in the analyses: Questions from the Child Survey: (1) Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? Questions from the Adult Survey: – (1) For how many days during the past 30 days did your mental health conditions or emotional problems keep you from doing your work or other usual activities? – (2) Do you need or get treatment or counseling for any kind of mental health status, substance abuse or emotional problem?

Mental Health Status and Barriers to Treatment Among Ohioans 10% of children and adults report having social, emotional, behavioral or substance abuse problems that require counseling . It was documented that with approximately 4% of adults, these mental health problems are so severe that they had resulted in at least 30 days of missed normal activities within the past year The prevalence of the mental health challenges reported is complicated by the fact that 8.7% of children and 16.7 % of adults did not have mental health coverage Furthermore, 23% of adults and 18% of parents were unsure of whether their plans included mental health coverage.

Mental Health Status and Barriers to Treatment Among Ohioans Key question used: Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? Children’s Demographic Trends and Risk Factors, including Comorbidities: Gender Age Race/Ethnicity Income Health Males were rated as having more problems. 13 – 17 years olds were rated as having more problems. Multi-racial and African-American children were at highest risk. Mental health problems increase as family income decreases. Obesity is a risk factor for poor mental health.

Mental Health Status and Barriers to Treatment Among Ohioans Child Risk Factors: Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? 55% 45% 35% 25% 15% 5% 42.6% 12.3% 13.0% Male 13-17 18.2% 15.7% 18.4% Multi-racial 100% FPL or below Obese Poor Mental Health

Mental Health Status and Barriers to Treatment Among Ohioans Key question used: Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? Children Most Likely to Delay Treatment: Age 13-17 years old (24.6%) Gender Female (4.9%) and Male (4.8%) Race Black/African-American (6.4%) Ethnicity Hispanic (6.4%) Income Insurance Type Insurance Status Uninsured (25.6%) Medicaid Coverage Region FPL - 101-150% (7.9%) and Directly Purchased (7.4%) No (5.0%) Rural, Non-Appalachian (5.8%) and Other (6.1%) 151-200% (7.9%)

Mental Health Status and Barriers to Treatment Among Ohioans Key question used: Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? Table I: Children’s Barriers to Seeking Mental Health Care Question What was the main reason you did not get the healthcare that was needed? Category Unmet Mental Health Need Percent Endorsed Unmet Doctor’s Visit or Exam Need Percent Endorsed Too expensive 36.9% 49.9% No Insurance 36.8% 40.9% Difficulty or delay in getting an appointment 17.0% 4.1%

Mental Health Status and Barriers to Treatment Among Ohioans Key question used: Do you need or get treatment or counseling for any kind of mental health status, substance abuse or emotional problem? Adults Demographic Trends and Mental Health Risk Factors: Age Race/Ethnicity Income Gender Education Marital Status Health There were two high risk groups: 1824 and 25-34. Multi-racial and African-American children were at highest risk. Mental health problems increased as income decreased. Males reported needing more help than females; females reported getting help more than males. Mental health problems increased as education decreased. Adults who were separated were at highest risk. Obesity, Hypertension, Diabetes, and Smoking were all risk factors.

Mental Health Status and Barriers to Treatment Among Ohioans Adult Risk Factors: Do you need or get treatment or counseling for any kind of mental health, substance abuse or emotional problem? 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 19.3% 14.6% 8.4% 9.2% Female 18-24 15.4% 9.4% Multi-racial 100% of FPL or below Obese Separated

Mental Health Status and Barriers to Treatment Among Ohioans Key question used: Do you need or get treatment or counseling for any kind of mental health status, substance abuse or emotional problem? Adult Subgroups Least Likely to Have Mental Health Coverage: Gender Age Race/Ethnicity Income Education Males 18-24 year olds African-American Families at 101-150% and 151200% of poverty Families with “less than high school” education

Mental Health Status and Barriers to Treatment Among Ohioans Key question used: Do you need or get treatment or counseling for any kind of mental health status, substance abuse or emotional problem? Adults Most Likely to Delay Treatment: Age Gender Race Ethnicity Income Marital Status Insurance Type Insurance Status Medicaid Coverage Education Region 25-34 years old (24.6%) Female (22.8%) Black/African-American (26.3%) and Other (30.7%) Hispanic (22.4%) FPL - 101-150% (31.7%) Divorced/Separated (29.8%) and Unmarried Couple (35.5%) Directly Purchased (23.2%) Uninsured (53.3%) Yes (21.2%) Some College (25.1%) Appalachian (23.2%)

Mental Health Status and Barriers to Treatment Among Ohioans Key question used: Do you need or get treatment or counseling for any kind of mental health status, substance abuse or emotional problem? Table II: Adult’s Barriers To Seeking Mental Health Care Question Category Unmet Mental Health Need Percent Endorsed Unmet Doctor’s Visit or Exam Need Percent Endorsed What was the main reason you did not get the healthcare that was needed? Too expensive 45.4% 54.2% No Insurance/ Insurance didn’t cover care 34.4% 33.6% Difficulty or delay in getting an appointment 9.5% 4.8%

Mental Health Status and Barriers to Treatment Among Ohioans Children 36.9% Too expensive Adults No Insurance/Insurance didn’t cover care Difficulty/Delay Getting an Appointment 45.4% Children 36.8% Adults 34.4% Children 17.0% Adults 9.5% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Parent-Child Health Trends Key Question from the Child Survey: (1) Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? Key Questions from the Adult Survey: (1) For how many days during the past 30 days did your mental health conditions or emotional problems keep you from doing your work or other usual activities? (2) Do you need or get treatment or counseling for any kind of mental health status, substance abuse or emotional problem? Children of parents who reported needing or getting treatment for mental health, substance abuse or emotional problems were more likely to also need or receive treatment (26.4%), compared to children of parents who did not need or receive treatment (8.4%). Parents that reported needing or getting treatment for mental health, substance abuse, or emotional problems were also more likely to rate their child’s mental health as fair or poor (14.1%), compared to parents not receiving or needing treatment (4.2%). Step-parents, foster parents and/or legal guardians were most likely to need or get treatment or counseling as well as miss 30 more days of usual activity due to mental health needs.

Regional Trends Key Question from the Child Survey: (1) Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? Table II: Region Children Mental Health Insurance, Mental Health Status and Unmet Needs by Question Child has mental health insurance coverage Does the child have any kind of emotional, developmental, or behavioral problem for which the child needs treatment or counseling? What was the health care that y our child st needed but did not get? (1 response Mental Health Care or Counseling ) Appalachian Metropolitan 92.0% Rural, Non Appalachian 89.5% 88.4% Suburban 93.1% 10.2% 10.1% 9.8% 9.8% 8.2% 13.2% 13.2% 6.9%

Regional Trends Key Questions from the Adult Survey: (1) For how many days during the past 30 days did your mental health conditions or emotional problems keep you from doing your work or other usual activities? (2) Do you need or get treatment or counseling for any kind of mental health status, substance abuse or emotional problem? Table III: Adults Mental Health Insurance, Mental Health Status and Unmet Needs by Region Question Appalachian Metropolitan Rural, NonAppalachian Suburban Adult has mental health care insurance coverage Do you need or get treatment or counseling for any kinds of mental health, substance abuse or emotional problem? For how many days during the past 30 days did your mental health condition or emotional problem keep you from doing your work or other usual activities? (30 days) What was the health care that you needed st but did not get? (1 response - Mental Health Care or Counseling) 78.2% 85.1% 79.3% 84.0% 7.4% 7.7% 6.5% 6.5% 5.3% 3.8% 3.8% 3.4% 5.1% 4.9% 4.6% 2.5%

Mental Health Status of Children and Adults on Medicaid Table IV. Mental Health Status of Children and Adults on Medicaid Ages 13-17 Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? Children on Medicaid 16.2% Other Multiracial Male 300% FPL or above Underweight Do you need or get treatment or counseling for any kind of mental health, substance abuse or emotional problem? Adults on Medicaid 21.7% Ages 45-54 Other Multiracial 100% FPL or below Obese

Mental Health Status of Children and Adults on Medicaid Key question used: Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? Children’s Demographic Trends and Medicaid Risk Factors: Gender Males were reported to have more needs for treatment or counseling for developmental or behavioral problems. Age As age increased, so did treatment needs and services. Race/Ethnicity Caucasians and African-Americans had higher treatment and service needs. Income Children in families at 300% of FPL had more needs. BMI Underweight and obese children had higher treatment and service needs. Physical Health Studies have shown that children with poor mental health generally have poorer physical health as well. Other Conditions Treatment and service needs were higher among children with diabetes and asthma.

Mental Health Status of Children and Adults on Medicaid Key question used: Does the child have any kind of emotional, developmental or behavioral problem for which the child needs treatment or counseling? Children on Medicaid Most Likely to Delay Treatment: Age Gender Race Ethnicity Income Region 13-17 years old (7.8%) Female (4.4%) Other (5.7%) and White/Caucasian (4.4%) Non-Hispanic (4.5%) and Hispanic (4.0%) FPL – 301% or more (6.4%) Rural, Non-Appalachian (7.7%)

Children on Medicaid: Regional Trends Table V: Children on Medicaid: Mental Health Insurance, Mental Health Status and Unmet Needs by Region Question Understands that child’s insurance plan covers mental health care Does the child have any kind of emotional, developmental, or behavioral problem for which the child needs treatment or counseling? What was the health care service that your child st needed but did not get? (1 response - Mental Health Care Counseling) Appalachian Metropolitan Rural, NonAppalachian Suburban 88.1% 91.9% 92.5% 89.2% 13.9% 14.8% 15.1% 11.5% 11.5% 13.8% 8.3% 0.0%

Mental Health Status of Children and Adults on Medicaid Key question used: Do you need or get treatment or counseling for any kind of mental health status, substance abuse or emotional problem? Adult’s Demographic Trends and Medicaid Risk Factors: Age The older the population, the more treatment needed (except for 65 - this can be attributed to Medicaid eligibility). Race/Ethnicity Hispanic and Caucasian populations needed the most treatment or services. Income Families at 100% of poverty or below needed the most services. Gender Treatment needs and services were higher among females. Education Service and treatment needs decreased as education increased Marital Status Separated and divorced individuals needed more treatment and counseling than any other group. BMI Obese individuals had higher reports of mental health services and treatment needs. Physical Health Poor physical health was related to higher service and treatment needs. Other Conditions Diabetes, hypertension, and smoking were the top three health problems experienced by the Medicaid population.

Mental Health Status of Children and Adults on Medicaid Key question used: Do you need or get treatment or counseling for any kind of mental health status, substance abuse or emotional problem? Adults on Medicaid Most Likely to Delay Treatment: Age Gender Race Ethnicity Income Marital Status Education Region 35-44 years old (27.7%) and 4554 years old (27.6%) Female (21.1%) Other (28.5%) and Asian (23.3%) Hispanic (20.5%) and NonHispanic (20.0%) FPL - 101-150% (22.5%) Unmarried Couple (26.7%) 4 year College Graduate (28.1%) Appalachian (21.7%)

Adults on Medicaid: Regional Trends Table VI: V: Adults Adultson onMedicaid Medicaid:Mental :Mental Health HealthInsurance, Insurance,Mental Mental Health Health Status and Unmet Needs by Region Question Appalachian Metropolitan Rural, NonAppalachian Suburban Insurance Plan Covers Mental Health Care 83.3% 86.5% 86.4% 83.7% Do you need or get treatment or counseling for any kinds of mental health, substance abuse or emotional problem? 20.5% 20.9% 21.3% 27.9% For how many days during the past 30 days did your mental health condition or emotional problem keep you from doing your work or other usual activities? 30 or more days 14.0% 9.6% 12.6% 11.6% What was the health care service that you needed but did not get? (1st response - Mental Health Care Counseling) 3.2% 4.8% 2.7% 2.7%

Summary of Results Both adults and children experienced unmet mental health needs due to barriers including cost and no insurance coverage. Additionally, the demographic and health risks were similar for children and adults. For children, being 13-17 years old, male and African-American or multiracial backgrounds were all associated with having more emotional, developmental or behavioral problems. Children from low-income families (100% below the federal poverty level), obese, and those with parents with less than a high school education also had more emotional, developmental or behavioral problems. For adults, males were at greatest risk for needing mental health care services; however, females were more likely to seek services. Finally, adults ages 45-64, minorities, separated couples and those with high school or less education were more likely to have treatment needs. These findings provide direction for clinical practice, research and public policy strategies, which are reviewed in this report.

Report Recommendations Future endeavors will need to ensure: – that clinical practice, research and policy support mental health and health integration – the development of new models of mental health care service delivery (including partnerships with community physicians and schools) – target children and adults at highest risk for mental health care challenges, notably those with disabilities, and low-income. At the same time, and as the survey findings suggest, mental heath problems are prevalent among every age and income bracket, as well as in every county and region of the state. It will be essential that Ohio develop creative, yet data-based, comprehensive, and personalized strategies for ensuring that children and adults have mental health insurance and access to quality care and providers.

Policy Recommendations to Improve the Mental Health among Ohioans Employers Should clearly document mental health benefits included in plans so that residents of all demographic and educational backgrounds understand their benefits as Ohio residents report not knowing whether their insurance covers mental health care (23% of adults), and parents report not knowing whether their child is covered (18% of parents). Mental health benefits need to be offered as part of a comprehensive insurance plan to all employees given that 63% of individuals who did not have mental health care coverage were employed

Policy Recommendations to Improve the Mental Health among Ohioans Mental Health and other Health Care Providers Will need to collaborate to identify patient needs and develop treatment plans according to the patient’s age, gender, individual needs and risk factors. Providers will also integrate mental health care into primary health care and other health care settings in order to facilitate assessment/screening, early detection, coordination of referrals and the co-morbidities associated with physical and mental health. Similarly, interventions have to be developmentally appropriate and behaviorally and culturally targeted to address youths’ specific needs. Given that health care providers are often the first point of contact, providers will need to make necessary referrals as mental and physical health conditions were co-morbid in children and adults.

Policy Recommendations to Improve the Mental Health among Ohioans Schools Often serve as the first point of contact for students and properly screen and address the mental health needs of students so that they can function optimally at school. All schools should have a mental health referral resource bank, which should consist of Medicaid providers and private insurers. Schools should also be trained in classroom behavioral management strategies and should have classroom level or school-wide level Prevention and Intervention Programs that could be easily implemented. Parents need to follow up on referrals that are made for their children by primary care physicians, schools and teachers.

Policy Recommendations to Improve the Mental Health among Ohioans Residents Should be proactive in understanding their health care plans so that they can make informed choices about benefits and treatment options. Seeking mental health care is important because mental health disorders such as depression, anxiety, alcoholism and drug abuse do not go away on their own. Without treatment, a mild problem may become severe, requiring a longer and more intensive treatment regimen once treatment is sought. Untreated mental illness may also cause disruption to one’s work and personal life if treatment is not sought.

Policy Recommendations to Improve the Mental Health among Ohioans Ohio Policy Makers Should focus on addressing the mental health needs of Ohio residents by providing mental health education and care, identifying the gaps in mental health insurance coverage, targeting high-risk and vulnerable child and adult populations, and ensuring parity in mental health and mental health coverage for high-risk and high-poverty Ohio residents.

References 1. 2. 3. 4. 5. 6. 7. 8. Bandiera F.C., Pereira, D.B., Arif, A.A., Dodge, B., & Asal, N. Race/ethnicity, income, chronic asthma, and mental health: A cross-sectional study using the behavioral risk factors surveillance system. Psychosomatic Medicine. 2007;70(1):77-84. Combs-Orme, T., Heflinger, C.A., & Simpkins, C.G. Comorbidity of mental health problems and chronic health conditions in children health. Journal of Emotional & Behavioral Disorders. 2002;10(2):116,111. Daly R. Governor's Change of Heart Gives Ohio New Parity Law. Psychiatry News. Vol 42; 2007:4. Groves, B.M. Mental Health Services for Children Who Witness Domestic Violence. Domestic Violence; 2002. Grupp-Phelan J., Whitaker, R.C., & Naish, A.B. Depression in Mothers of Children Presenting for Emergency and Primary Care: Impact on Mothers' Perceptions of Caring for Their Children. Ambulatory Pediatrics. 2003;3(3):142-146. Johnson, A. Billions for health care? The Columbus Dispatch, 2008. Judge Brown Bazelon Center for Mental Health Law. Left behind: data on adults and children with mental health disorders in families on TANF. Washington, DC; 2002. Kessler R.C., Chiu W.T., Demler, O., & Walters, E.E. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCSR).Archives of General Psychiatry. 2005;62(6):617-627.

References 9. 10. 11. 12. 13. Larkin, G.L., Claassen, C.A., Edmond, J.A., Pelletier, A.J., & Camargo, C.A. Trends in US emergency department visits for mental health conditions. Southwestern Medical Center. 2002;56(6):671-667. Laveist, T.A. Race, Ethnicity, and Health. San Francisco: Jossey-Bass; 2002. Lawrence, S., Chau, M., & Lennon, M. Depression, Substance Abuse, and Domestic Violence. New York: Columbia University; 2004. National Center for Children in Poverty. Children’s Mental Health: Facts for Policymakers. 2006 Ohio Revised Code Sections 1751.01, 3923.28, 3923.281 and 3923.282. www.Ohioinsurance.gov