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Mh Mental Health Issues Mental Health Issues HP 2020 Goal Improve mental health through prevention and by ensuring access to appropriate, quality mental health services. HP 2020 Objectives Reduce the proportion of persons who experience major depressive episodes (MDEs). Targets: 7.4% among adolescents 12 to 17 years old 5.8% among adults 18 years old and older. Increase the proportion of adults 18 years old and older Target: 78.2% with major depressive episodes who receive treatment. Mental disorders are responsible for a high degree of burden due to illness.2 According to the 1999 Surgeon General’s report on mental health, only about 17 percent of U.S. adults are considered to be in a state of optimal mental health.1 Owing to this growing burden of mental disorders, it is essential that effective preventive and promotional measures be taken in mental health to reduce the impact of mental disorders on the individual and society.2 In 2010, about 8.5 percent of adults 18 years old and older had 14 or more days of poor mental health in the previous 30 days.17 In 2011 about 22 percent of Kansas high school students in grade 9-12 felt so sad or hopeless almost every day for two weeks or more in a row during the previous 12 months that they stopped doing some usual activities.29 Depression and anxiety, the two Summary Mental health and mental illness, terms that describe the continuum of mental function,1 constitute an integral part of overall health.2 Thus, to attain status of overall health, improvement of the mental health of individuals is essential. 153 leading mental health issues, are prevalent conditions in Kansas.17 Disparities are also seen in the burden of these mental health issues in the population sub-groups. Out of 105 counties in Kansas, 99 counties are considered partial or whole mental health professional shortage areas.30 To improve the overall health of Kansans, it is important to address leading mental health issues and associated disparities through prevention and by ensuring access to appropriate, quality mental health services. Definition and Introduction Mental health and mental illness, terms that describe the continuum of mental function,1 constitute an integral part of overall health, which is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”2 Mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”1,3 According to the 1999 Surgeon General’s report on mental health, only about 17 percent of U.S. adults are considered to be in a state of optimal mental health.1 The emerging knowledge through research in this field is indicating that positive mental health is 154 related to improved health outcomes.4 Mental illness is defined as “collectively all diagnosable mental disorders” or “health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.”2,4 Mental disorders are among the most common causes of disability and resulting disease burden and mental illness is among the highest of all diseases. In any given year, an estimated 13 million American adults (about 1 in 17) have a seriously debilitating mental illness.5,6 Mental health disorders are the leading cause of disability in the United States, accounting for 25 percent of all years of life lost to disability and premature mortality.7 Also, suicide is the 11th leading cause of death in the United States, causing about 30,000 deaths each year.8,9 Depression is the most common type of mental illness, affecting more than 26 percent of the U.S. adult population.5 It is associated with increased risk of morbidity, mortality and impaired quality of life.12 Depressive and related depressive disorders are the cause of more than two-thirds of suicides each year.13 Depression is a risk factor for noncompliance of medical treatment and may increase severity of a disease.12 It is also a costly disease; an estimated $83 billion were spent on direct and indirect cost in the United States.14 Studies indicate that mental disorders, especially depressive disorders, are strongly related to the occurrence, treatment outcomes, and course of many chronic diseases including diabetes, cancer, cardiovascular disease, asthma, and obesity and associated risk behaviors such as physical inactivity, smoking, excessive drinking, and insufficient sleep.4,10 The Healthy People 2010 plan had included Mental Health as one of the 10 leading indicators for monitoring health status of the nation and has recommended increasing the proportion of adults with recognized depression who receive treatment. Mental Health and Illness Status in Kansas Diagnosed Depression, Current Depression and Anxiety Depression and anxiety, the two leading mental health issues, are prevalent conditions in Kansas. Disparities are seen in the burden of these conditions among various socio-demographic subgroups and among those with other chronic diseases and disability.15 The types of depression include major depression disorder (MDD), minor depression, dysthymia and bipolar disorder. Depression symptoms include persistent sad, anxious or “empty” mood; feelings of hopelessness, pessimism, guilt, worthlessness, or helplessness; loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex; decreased energy, fatigue or being “slowed down”; difficulty concentrating, remembering or making decisions; insomnia, early-morning awakening or oversleeping; appetite and/or weight loss or overeating and weight gain; thoughts of death or suicide, or suicide attempts; restlessness or irritability; persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain.16 adapted set of PHQ questions are referred as PHQ-8. The population-based mental health information obtained through the application of this PHQ-8 tool is used to develop a scoring system to define different levels of severity of depression. Based on this scoring system, different levels of severity of depression are defined as no depression (score 0-4), mild (score 5-9), moderate (score 10-14), moderately severe (score 15-19), and severe depression (score ≥ 20). In addition, based on this scoring system, depression is classified into two groups - current depression (score ≥ 14) and no current depression (score < 14). Anxiety disorders are considered the most prevalent mental disorder among adults in the United States.19,20 In a given year, an estimated 40 million or 18.1 percent of adults are affected with an anxiety disorder.19,20 It is estimated that half of American adults diagnosed with major depression are also diagnosed with a type of anxiety disorder.21 Individuals with an anxiety disorder tend to make more frequent trips to the doctors, and are six times more likely to be hospitalized for psychiatric disorders.20 Despite being in the presence of health care professionals, the symptoms of an anxiety disorder can easily In Kansas, a population-based health surveillance system17 – the Behavioral Risk Factor Surveillance System (BRFSS) collects information on ever being diagnosed with depression (includes major depression, dysthymia, or minor depression). In addition, Kansas BRFSS also uses eight questions to collect information on mood status and depressive symptoms of the individuals. These questions are adapted and modified from the Patient Health Questionnaire - Version 9 (PHQ)11,18 and include eight of the nine criteria’s for the diagnosis of depression listed in the Diagnostic and Statistical Manual disorders, Fourth Edition Text Revision (DSM-IV-TR). This 155 be masked with physical illnesses therefore proper treatment of the disorder is difficult.14,20 Scientific literature shows that people suffering from both a major depression and general anxiety disorder have significantly greater disability as opposed to those suffering from just one of the disorders.22 The type of anxiety disorders include acute stress disorder (ASD), generalized anxiety disorders (GAD), obsessivecompulsive disorder (OCD), panic disorder (PD), post-traumatic stress disorder (PTSD), social anxiety disorder (also known as social phobia), and specific phobias such as fear of heights and spiders.23 Kansas BRFSS also collected population-based information on ever being diagnosed with anxiety.17 About 1 in 7 (14.7%) Kansans 18 years old and older have ever been diagnosed with depression and about 1 in 14 (7.6%) have current depression (Score ≥ 14 based on PHQ-8 tool). About 1 in 10 (10.3%) Kansans 18 years old and older have ever been diagnosed with anxiety.15,17 Prevalence of Ever Being Diagnosed With Depression, Current Depression and Ever Being Diagnosed With Anxiety among Adults Ages 18 Years and Older, Kansas 2006, 2008 & 2010 Sources: 2006-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, KDHE. It is important to note that based on PHQ-8 scores, about 24 percent of Kansas adults 18 years old and older have mild to severe depression as compared to 14.7 percent of Kansas adults who have doctor diagnosed depression.15 Thus, a considerable percentage of adults has some degree of depression without being diagnosed by a physician. Diagnosed Depression, Current Depression and Anxiety Among Kansas Socio-Demographic Groups Disparities in the prevalence of ever being diagnosed with depression are seen among various sociodemographic sub groups in Kansas.15 About 1 in 5 females has ever been diagnosed with depression as compared to 1 in 10 males.15,17 Higher prevalence of ever being diagnosed with depression is seen among adults 35 to 64 years old, those who are divorced or separated, unemployed, unable to work, and with lower education and income status.15,17 A higher prevalence of ever being diagnosed with depression is seen among adults without health care coverage as compared to adults with health care coverage.15,17 About 1 in 3 adults who needed to see a doctor in the previous 12 months but did not because of the cost has depression.15,17 156 Severity Levels of Depression Among Adults 18 Years and Older, Kansas 2010 Source: 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, KDHE. Disparities are also seen in the prevalence of current depression in Kansas.15 About 1 in 10 females are currently depressed as compared to 1 in 17 males.15,17 The prevalence of current depression is also higher among adults who are divorced or separated as compared to adults who are married; among adults with less than high school education as compared to adults who are college graduates; among adults 35 to 54 years old; those with lower income; and those who are unable to work.15,17 A higher prevalence of current depression is seen among adults without health care coverage as compared to adults who have health care coverage.15,17 In Kansas 1 in 4 adults who needed to see a doctor in the previous 12 months but could not because of the cost has current depression.15,17 Similar disparity patterns are seen for the prevalence of ever being diagnosed with anxiety; however, there is no statistical difference in the prevalence of ever being diagnosed with anxiety among adults with different educational levels. About 1 in 8 Kansas females have ever been diagnosed with anxiety as compared to 1 in 13 males.15,17 The prevalence of ever being diagnosed with anxiety is higher among adults who have lower annual household income (< $15,000) and are unable to work as compared to adults with higher annual household income (>= $50,000) and who are employed.15,17 The prevalence of ever being diagnosed with anxiety is also higher among adults who are divorced or separated and who are never married as compared to adults who are married; and among those who reside in an urban region of the state as compared to adults who reside in a frontier region.15,17 In Kansas 1 in 5 adults who needed to see a doctor in the previous 12 months but did not because of the cost has anxiety.15,17 157 Diagnosed Depression, Current Depression and Anxiety Among Kansas Adults with Chronic Diseases, Chronic Disease Risk Factors and Those Living with a Disability Disparities in the prevalence of ever being diagnosed with depression, current depression and ever being diagnosed with anxiety are seen among those with other chronic diseases, chronic disease risk factors and among those living with a disability.15 The prevalence of being ever diagnosed with depression is higher among those with chronic diseases such as current asthma and stroke.15,17 The higher prevalence is also seen among obese adults, current cigarette smokers and those who do not participate in leisure time physical activity.15 In Kansas 1 in 3 adults who rate their health as fair or poor has ever been diagnosed with depression as compared to 1 in 8 who rate their health as excellent, very good or good.15,17 The prevalence of ever being diagnosed with depression is also higher among adults living with disability as compared to adults living without a disability.15 The prevalence of current depression is higher among those with chronic diseases such as stroke and current asthma.15,17 The prevalence is also higher among current cigarette smokers, obese adults and those who do not participate in leisure time physical activity.15,17 In Kansas 1 in 4 adults who rate their health as fair or poor has current depression as compared to 1 in 20 who rate their health as excellent, very good or good. The prevalence of current depression is also higher among adults living with disability as compared to adults living without a disability.15 Higher prevalence of ever being diagnosed with anxiety is seen among those with chronic disease such as current asthma, coronary heart disease, and stroke. Higher prevalence of ever being diagnosed with anxiety is also seen among current smokers.15,17 In Kansas 1 in 5 adults who rate their health as fair or poor are ever been diagnosed with anxiety as compared to 1 in 12 who rate their health as excellent, very good or good.15,17 The prevalence of ever being diagnosed with anxiety is also higher among adults living with disability as compared to adults living without a disability.15 Depression Treatment in Kansas About 2 in 5 (43.5%) Kansas adults ages 18 years and older who have symptoms of depression during a period of two weeks and longer in the previous 12 months receive treatment for depression (any treatment or hospitalization for sadness, discouragement or lack of interest at any time in the past 12 months).15 The top three reasons for not receiving treatment are no reason for not seeking treatment (27.5%), inability to afford the treatment (23.0%), and not feeling the need or feeling symptoms are not severe enough to receive the treatment (21.1%).15 One of the 10 leading health indicators for Healthy People 2010 was to increase the proportion of adults with recognized depression who receive treatment to 64 percent. Further efforts are needed in Kansas to meet this objective. 158 Prevalence of Serious Psychological Distress in Kansas Serious Psychological Distress (SPD) is a nonspecific measure of psychological distress that has been psychometrically validated and shown to be able to distinguish community DSM-IV cases from non-cases.24,25,26,27 SPD is determined using Kessler 6 (K6) scale. This scale is widely used nationally and internationally in epidemiological studies and surveys assessing mental illness. Another measure of mental illness is Frequent Mental Distress (FMD). FMD is calculated by number of days reported as mental health was not good in past 30 days by respondents and categorized as positive for 14 or more days. Kansas BRFSS has provided information on the population level prevalence of SPD and FMD among adults ages 18 years and older. About 2.5 percent of Kansans 18 years old and older have SPD and about 8.6 percent have FMD.28 Serious Psychological Distress Among Socio-Demographic Groups in Kansas Prevalence of serious psychological distress is higher among adults who have less than high school education as compared to those who are college graduates; among those with annual household income less than $15,000 as compared to those with higher annual household income; among adults who are unable to work as compared to adults who were self-employed or employed for wages, retired, homemakers or students; and among divorced or separated individuals as compared to married, members of unmarried couple and never married individuals.28 Higher prevalence of SPD is seen among adults without health insurance or coverage as compared to those with health insurance or coverage.28 Serious Psychological Distress Among Adults with Chronic Diseases, Chronic Disease Risk Factors and Those Living with a Disability in Kansas Higher prevalence of SPD is seen among adults with arthritis as compared to adults without arthritis; among adults with diabetes as compared to adults without diabetes; among adults with hypertension as compared to adults without hypertension; among adults with current asthma as compared to adults without current asthma; among adults with coronary heart disease as compared to those who did not have coronary heart disease; and among adults who have had a stroke as compared to those who did not have a stroke. Higher prevalence of SPD is observed in current smokers as compared to nonsmokers; among those who do not participate in any physical activity or exercise other than their regular job (leisure time physical activity) as compared to those who participate in leisure time physical activity; and among those who are inactive as compared to those who participate in recommended level of physical activity and in insufficient physical activity. Higher prevalence of SPD is observed among people living with a disability as compared to people living without a disability.28 159 Serious Psychological Distress Treatment in Kansas Only about half of adults with SPD (49.7%) receive medicine or treatment from a doctor or other health professional. Fewer than half of adults with FMD (41.5%) receive medicine or treatment from a doctor or other health professional.28 Other Measures Mental Health and Youth in Kansas In 2011 1 in 5 (21.9%) Kansas high school students in grade 9-12 felt so sad or hopeless almost every day for two weeks or more in a row during the previous 12 months that they stopped doing some usual activities.29 The prevalence of feeling sad or hopeless is higher among female students as compared to male students.29 Kansas Mental Health Professional Shortage Areas Out of 105 counties in Kansas, 99 counties are considered partial or whole mental health professional shortage areas.30 160 References 1. U.S. Department of Health and Human Services. Mental Health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance abuse and Mental Health, National Institutes of Health, National Institute of Mental Health; 1999. Available at: http:// profiles.nlm.nih.gov/ps/access/NNBBHV.pdf. Accessed October 30, 2014. 2. World Health Organization. Strengthening Mental Health Promotion. Fact sheet no. 220. Geneva,CH: World Health Organization; 2001. 3. U.S. Department of Health and Human Services. Mental Health and Mental Disorders. Healthy People 2020 website. U.S. Department of Health and Human Services. Available at: http://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders. Accessed October 30, 2014. 4. National Center for Chronic Disease Prevention and Health Promotion. Mental Health Basics. Centers of Disease Control and Prevention website. 2013. Available at: http://www.cdc.gov/mentalhealth/basics.htm. Accessed October 30, 2014. 5. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617–627. 6. U.S. Census Bureau, Population Division. US Census Bureau population estimates by demographic characteristics: National population estimates—characteristics. Table 2 (NC-EST2004-02): Annual estimates of the population by selected age groups and sex for the United States: April 1, 2000, to July 1, 2004; A18. Washington: US Census Bureau; 2005 Jun 9. 7. The World Health Organization (WHO). The world health report 2004: Changing history. Annex Table 3: Burden of disease in DALYs by cause, sex, and mortality stratum in WHO regions, Estimates for 2002; A126-A127. Geneva, CH: WHO; 2004. 8. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIP). Web-based injury statistics query and reporting system (WISQARS) [Internet]. Atlanta: CDC; 2010. Available at: http://www.cdc.gov/ncipc/wisqars. 9. National Institutes of Health, National Institute of Mental Health (NIMH). NIMH strategic plan (revised 2008) [Internet]. Bethesda, MD: NIMH; 2008 [cited 2010 May 6]. Available at: http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml. 10.Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14. 11.Kroneke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine. 2001;16: 606-613. 12.Martin A, Rief W, Klaiberg A, Braehler E. Validity of the brief Patient Health Questionnaire (PHQ-9) mood scale in the general population. General Hospital Psychiatry. 2006;28:71-77. 13.U.S. Department of Health and Human Services. Mental Health: Leading Health Indicator. Healthy People 2010 website. 2010. Available at: http:// www.healthypeople.gov/2010/?visit=1. Accessed February, 2012. 14.Greenburg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? Journal of Clinical Psychiatry. 2003;64:1465-1475. 15.Kansas Department of Health and Environment. Depression and Anxiety Status in Kansas: 2010 Behavioral Risk Factor Surveillance System. Topeka, KS: Bureau of Health Promotion, Kansas Department of Health and Environment; 2012. Available at: http://www.kdheks.gov/brfss/ PDF/2010_Kansas_Depression_and_Anxiety_Status.pdf. Accessed October 30, 2014. 16.National Institute of Mental Health. Depression. National Institute of Mental Health website. 2012. Available at: http://www.nimh.nih.gov/health/ publications/depression/complete-index.shtml. Accessed February, 2012. 17.2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. Available at: http://www.kdheks.gov/brfss/index.html. 18.Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD. The PHQ Primary Care Study. Journal of the American Medical Association. 1999;282(18):1737-1744. 19.Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry. 2005;62:617-627. 20.Anxiety Disorders Association of America. Statistics and Facts about Anxiety Disorders. Anxiety Disorders Association of America website. 2012. Available at: http://www.adaa.org/about-adaa/press-room/facts-statistics. Accessed February, 2012. 21.Anxiety Disorders Association of America. Anxiety and Depression: What to do when you have both. Anxiety Disorders Association of America website. Available at: http://www.adaa.org/GettingHelp/MFarchives/MonthlyFeatures(september).asp. Accessed February, 2012. 22.Grant BF, Hasin DS, Stinson FS, et al. Prevalence, correlates, co-morbidity, and comparative disability of DSM-IV generalized anxiety disorder in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine. 2005;35(12):1747-59. 23.National Institute of Mental Health. Anxiety Disorders. National Institute of Mental Health website. 2006. Available at: http://www.nimh.nih.gov/ health/topics/anxiety-disorders/index.shtml. Accessed February, 2012. 24.Shih M, Hootman JM, Strine TW, Chapman DP, Brady TJ. Serious Psychological Distress in U.S. Adults with Arthritis. Journal of General Internal Medicine. 2006;21:1160–1166. 25.Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002; 32(6):959-76. 26.Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003;60:184–9. 27.Furukawa TA, Kessler RC, Slade T, Andrews G. The performance of the K6 and K10 screening scales for psychological distress in the Australian national survey of mental health and well-being. Psychol Med. 2003;33:357–62 28.Kansas Department of Health and Environment. Mental Illness and Stigma Status in Kansas: 2009 Behavioral Risk Factor Surveillance System. Topeka, KS: Bureau of Health Promotion, KDHE; 2011. Available at: http://www.kdheks.gov/brfss/PDF/2009_Mental_Illness_Stigma_Report.pdf. 29.2011 Kansas Youth Risk Behavior Survey. Kansas State Department of Education. Available at: http://www.kshealthykids.org/HKS_Menus/HKS_ Home.htm. 30.Mental Health HPSAs - 2012. Bureau of Community Health Systems. Kansas Department of Health and Environment. Available at: http://www. kdheks.gov/olrh/SD.htm. 161 Strengths and Assets Strengths There are several promising practices that are in the early stages, but the work needs additional support to continue and be successful. These programs include Mental Health First Aid, Psychological First Aid, Crisis Intervention Training, and Strategic Brief Intervention and Referral to Treatment. There is strong movement toward integration between primary care and behavioral health with at least 11 community mental health centers and 10 safety net clinics in 13 communities. Substance use disorder providers are also working on integration and collaboration. Assets ●● Values of Kansans – compassionate and hardworking, resulting in caring, concern, and action that happens oneon-one and among families, friends, faith communities, and organizations ●● Widespread belief that recovery is possible ●● Consumer involvement in policy development and planning, consumer-run organizations, National Alliance on Mental Illness - Kansas ●● Comprehensive Community Mental Health Center system - though under-funded, it is an ultimate safety net because every county is covered ●● Strong Association of Community Mental Health Centers in Kansas ●● Integration of mental health and substance abuse programs at the state level ●● Multiple promising practices and programs currently under development, including primary care-behavioral health integration initiative; community education programs like mental health first aid, psychological first aid, and crisis intervention training; and strategic brief intervention and referral to treatment (SBIRT) 162