1998 Community Assessment

Adult Mental Health

A. Issue Summary

B. Background and Influencing Factors

C. Outcomes and Key Indicators

• Increased number of adults and their family members who are aware of mental health issues
• Increased number of adults demonstrating adequate, productive coping behavior
• Increased number of adults reporting achievement of personal and treatment plan goals
• Increased number of adults who remain stable and in the community
• Increased number of adults and their family members reporting increased satisfaction with services
• Decreased number of adults and their family members reporting difficulty in accessing appropriate and comprehensive mental health services
• Decreased number of adults whose mental health status has negatively impacted their lives, including their ability to work
• Decreased number of adults who attempt or commit suicide

D. Other Key Outcomes and Status

A. ISSUE SUMMARY

Strategies for Building a Stronger Community: A Community Guide

The key findings regarding adult mental health outcomes from the CAN Community Guide are:

• Adult Suicide. In Travis County for the years 1986 to 1996, suicides outnumbered deaths from breast cancer and were twice as frequent as homocides. Males are more likely to commit suicide than women. In 1996, the death rate for males was 23.4 per 100,000, whereas the female death rate was 8.8 per 100,000.
• Psychiatric Hospitalization Admission/Recidivism. In Travis County the number of ATCMHMR consumers in Medical Support Services receiving Case Management is at a four year low. The trend over this period of time has shown a 42% decrease.
• Psychopharmacology. One recurring factor influencing the productiveness of an adult with severe and persistent mental illness is the availability and affordability of effective new generation medication(s). When the new generation of medications are compared with the old, there is a significant increase in quality of life. Public agencies and their consumers are finding it increasingly difficult to support the cost of these newer medications. Many of the older generation medications that are affordable have very debilitating side effects that reduce client compliance with their medication treatment regimen.

Three outcomes for which no appropriate data have been identified are:

• Increase goal achievement among adults that are mentally ill
• Increased adult and family awareness of mental health issues
• Decreased number of adults and their family members reporting difficulty in accessing appropriate and comprehensive mental health services

This issue summary represents a great step forward in the communitys understanding of an overwhelming problem. Assessment of community problems, needs, and desired outcomes is an ongoing process and will need to include data from all local public and private agencies and organizations, including data needed to track outcomes not currently identified.

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B. BACKGROUND AND INFLUENCING FACTORS

Excerpt from the 1997 Community Guide:

Guiding principles for the delivery of mental health services within the continuum include:

• appropriate services provided by qualified professionals;
• cost-efficient and effective services which produce improved outcomes;
• services tailored to the individual needs and developmental stages of clients and their families;
• provision of services within appropriate therapeutic/community environments;
• services provided holistically so that the full range of health needs of individuals are addressed concurrently; and,
• sufficient capacity to serve the adult mental health need.

Characteristics of populations at risk for mental illness include the following:

• genetic predisposition;
• family history; and
• environmental difficulties.

These characteristics can be exhibited through one or more of the following:

• difficulty in obtaining basic needs (i.e., nutrition, obtaining or maintaining housing, and hygiene);
• do not have the resources, ability, or motivation to make good life choices personally or professionally;
• difficulty with parenting skills;
• difficulty in demonstrating adequate or productive coping behavior;
• poor self-esteem; and,
• difficulty with obtaining or maintaining employment.

Importance to the Community

Mental health is the ability of an individual to negotiate the daily challenges and social interactions of life. However, mental health can be affected by numerous factors ranging from biological and genetic vulnerabilities, acute or chronic physical dysfunction, and/or environmental conditions and stresses. An estimated 10-15 percent of adults living in Travis county are severely incapacitated by mental disorders, with almost 20 percent having experienced at least one diagnosable disorder at some point in their lives. Suicide is clearly the most serious potential outcome of mental disorders. Schizophrenic disorders, which can produce the most complex functional disabilities, affect about 1 percent of the adult population. Clinically defined major depression and associated affective/mood disorders affect approximately 5% percent of the population at any given time.

Mental illness is a complicated individual, family, social, economic, and political problem that effects the community in several ways, for example:

• increased difficulties with family relationships;
• decreased quality of life;
• decreased productivity at work;
• Increase in homelessness; and,
• increased tax-supported services.

To ameliorate these impacts, the community must address both the emotional and economic effects of mental illness. This includes identifying those individuals with mental illness and coordinating services between public and private providers.

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C. OUTCOMES AND KEY INDICATORS

The eight outcomes that will be analyzed in the next section are:

• Increased number of adults and their family members who are aware of mental health issues
• Increased number of adults demonstrating adequate, productive coping behavior
• Increased number of adults reporting achievement of personal and treatment plan goals
• Increased number of adults who remain stable and in the community
• Increased number of adults and their family members reporting increased satisfaction with services
• Decreased number of adults and their family members reporting difficulty in accessing appropriate and comprehensive mental health services
• Decreased number of adults whose mental health status has negatively impacted their lives, including their ability to work
• Decreased number of adults who attempt or commit suicide

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OUTCOME: Increased number of adults and their family members who are aware of mental health issues

Currently no Travis County adult mental health providers, public or private adult psychiatric care providers, or related associations gather data on this outcome.

National statistics state that nearly two out of three people do not know that mental illnesses have physiological causes, and one in four think people bring depression upon themselves.

Possible methods to achieve this outcome could include:

Mental disorders include a variety of conditions that seriously interfere with interpersonal relationships, productivity at school/work, etc. This continuum of mental disorders includes schizophrenia, depression, anxiety, phobias, panic attacks, and more. Although the psychobiological factors that lead to the development and maintenance of these disorders have not yet been fully identified, primary prevention, early identification, and appropriate application of available treatment support, and rehabilitation technology are factors that can reduce the likelihood of the disability becoming more progressive.

Individuals with severe and persistent mental illness in Travis County are a vulnerable population group that have experienced intensive service interventions. As a result, most have had difficulty with economic self-sufficiency, personal care, interpersonal/family relationships, social support, housing, and medication side-effects. Community services has greatly impacted the reduction of these difficulties for this vulnerable population.

Major depression is characterized by prolonged and unrelenting sad mood, loss of interest in virtually all activities, changes in eating and sleeping patterns, and sometimes suicidal thoughts. Depressive disorders often affects those individuals between the ages of 25 and 44. The 1998 HP2000 survey found that nationally, approximately 12% of households included at least one depressed individual, while approximately 18% of the Austin MSA households included someone who was/is depressed. Included in this group are bipolar disorder (characterized by severe mood swings) and dysthymia a long-lasting disorder with fewer and less incapacitating mood swings. An estimated 20 percent of those who experience major depressive disorders are not seen in any service settings.

The most common of the major mental disorders is anxiety disorders. These disorders range from fairly circumscribed phobias, such as a fear of snakes, to global, highly incapacitating disorders, such as panic disorder and obsessive compulsive disorder. Fortunately, highly effective treatments have been developed, including behavioral, cognitive, and pharmacological approaches. This makes early diagnosis and treatment of significant importance in reducing impairment. However, as with depressive disorders, persons with anxiety disorders often do not seek appropriate treatment in the early stages of the disorder.

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OUTCOME: Increased number of adults demonstrating adequate, productive coping behavior

While this outcome is very important to providers and policy makers alike, the statistical information to support this outcome is limited. The only provider that was able to provide useful data on this outcome was ATCMHMR.

One recurring factor influencing the productiveness of an adult with severe and persistent mental illness is the availability and affordability of effective new generation medication(s). When the new generation of medications are compared with the old, there is a significant increase in quality of life. Public agencies and their consumers are finding it increasingly difficult to support the cost of these newer medications. Many of the older generation medications that are affordable have very debilitating side effects that reduce client compliance with their medication treatment regimen.

Three of ATCMHMR's assessment instruments used to measure client's level of functioning are: 1) GAF, 2) MCAS, and 3) BPRS.

Global Assessment of Functioning Scores

On the Global Assessment of Functioning (GAF) Scale, a score of 41-50 denotes serious symptoms (e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).

A score of 51-60 would indicate, moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).

The most current GAF mean score for ATCMHMR clients was 50.1, slightly higher than the Texas mean score, 48.8. Both of these scores represent the high-end range of adults with serious functioning impairment and include clients who began receiving services with a lower GAF score and improved within the fiscal year.

Multnomah Community Ability Scale (MCAS)

This scale is intended for use with people who have a severe and persistent mental illness. It is divided into four sections: 1) Interference with functioning; 2) Adjustment to living; 3) Social competence; and 4) Behavioral problems. Scoring for sections 1-3 are based on level of functioning during past 3 months and section 4 is based on level of functioning during past 12 months. Lower scores reflect greater problems.

The most current MCAS mean score for ATCMHMR clients was 60.4, slightly lower than the Texas mean score, 61.3. This score shows that the adults being treated by ATCMHMR have slightly more problems in the community, when compared to adults being treated throughout Texas.

Brief Psychiatric Rating Scale (BPRS)

This scale used both self-report and clinical observation to measure a client's level of functioning.

The most current BPRS mean score for ATCMHMR clients was 35.9, lower than the Texas mean score, 47.9. Higher scores reflect greater symptomology. These scores indicate that ATCMHMR clients exhibit less symptomology, when compared to Texas' mean BPRS score.

Table 4.8.1

GAF, BPRS and MCAS Scores Travis County and Texas *

Table 4.8.2

Source: TXMHMR CARE Report for Adult MH Priority Population, 4th QRT, FY 1997, p. 3. **No trend data was available.

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OUTCOME: Increased number of adults reporting achievement of personal and treatment plan goals

ATCMHMR for many years has collected, coded and monitored individual consumer progress. Currently, ATCMHMR does not have an automated record of how the agency as a whole is performing on this outcome. However, a current pilot study has been initiated concerning this issue, part of which is to automate the 90-day review process for ATCMHMR consumers.

The private sector adult mental health providers do not have a mechanism in place to systematically report on goal achievement of their adult mental health consumers.

The data available to address this outcome comes from the 1997 Texas MHMR Mental Health Consumer Survey, which states:

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OUTCOME: Increased number of adults who remain stable and in the community

The chosen indicators for this outcome were admission and recidivism rates for acute care facilities in Travis County. Individuals served by ATCMHMR spend less time in the hospital than individuals served by MHMR community centers in other parts of Texas. It should be noted, that the number of consumers hospitalized is at a four year low.

Table 4.8.3

Mean Local Psychiatric Hospitalization Days per Person

Table 4.8.4

ATCMHMR Consumers in Medical Support Services that receive Case Management

* Fiscal Year 1998 to date (September 1997 to May1998)

Source: Austin Travis County MHMR, Hospitalization Report

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OUTCOME: Increased number of adults and their family members reporting increased satisfaction with services

ATCMHMR was the only provider able to report data concerning satisfaction ratings for its consumers. The private sector providers did not have the ability to produce statistics to support their client satisfaction ratings. The overall, ATCMHMR consumer satisfaction ratings were above the states required goal.

Table 4.8.6

Consumer Satisfaction with Adult Mental Health Services

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OUTCOME: Decreased number of adults and their family members reporting difficulty in accessing appropriate and comprehensive mental health services

The only recent source of data for this outcome has come from ATCMHMR which is the 1998 4th quarter report. Private providers do not collect this data. An important point to note is that ATCMHMR currently provides services to about 25% more individuals than it is contracted to do. This increased strain on the public system, with no additional resources is especially noticable when the increased cost of new medications is factored into the equation. The ATCMHMR's Single Point of Entry (SPOE) program provided the following data.

Out of the 3,100 consumers served by ATCMHMRs Adult Mental Health Network per month, the following data is available:

• Consumers living in the community who did not enter through another program waited an average of less than 14 days from the time they called to the time they were assessed
• For consumers discharged from Austin State Hospital the average wait was less than 6 days

  Source: Austin Travis County Mental Health Mental Retardation Center Intake Report 4th Qrt: FY 1998.

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  OUTCOME: Decreased number of adults whose mental health status has negatively impacted their lives, including their ability to work

  Table 4.8.7

  Uniform Assessment Measures

  Employment Type			Days Employed in Past 90 Days
  	None	Non-Supportive	0 Days	61 to 90
  ATCMHMR	54%	22%	49%	17%
  Texas MHMR	15%	60%	57%	12%
  Private Providers	N/A	N/A	N/A	N/A

  **Note: Days employed within the 1 to 60 days range was no more than 4% of the total.

  Source: TXMHMR CARE Report for Adult MH Priority Population, QRT 4, FY 1997.

   

  Table 4.8.8

  Housing and Financial Status Among Priority Population Travis County

  	Residence Type			Financial Support
  	Supportive	Non-Supportive	None	Family	Soc. Sec	Wages
  ATCMHMR	12%	53%	10%	11%	35%	22%
  TXMHMR	7%	63%	6%	15%	41%	16%
  Private Providers	N/A	N/A	N/A	N/A	N/A	N/A

  Note: Categories comprising <=4% of residence types were not included in this table.
  Source: TXMHMR CARE Report for Adult MH Priority Population, QRT 4, FY 1997

  **No available trend data.

  Private providers have been unable to provide data on the negative impacts their consumers have experienced as a result of mental illness. County-wide results from a community needs survey conducted in 1995 by Health Partnership 2000's Community needs survey 1993/1995. (Unpublished) indicated that:

  • Approxamately one out of four Travis County residents report that they have accomplished less than they would have liked due to feelings of depression and/or anxiety
  • Approxamately one out of six Travis County residents report that they are not employed or are involved in other community activities due to feelings of depression and/or anxiety
  • In 1994 and 1995, approxamately one out of ten Travis County residents were treated by a mental health professional for an emotional or family problems

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  OUTCOME:Decreased number of adults who attempt or commit suicide.

  Suicide trend data at the county, state, and national level are available. Data for suicide by age, sex, and ethnicity for a 10-year period shows:

  • The overall suicide rates for Travis County are decreasing among both males and females. Males are more likely to commit suicide than women. In 1996, the death rate for males was 23.4 per 100,000, whereas the female death rate was 8.8 per 100,000
  • Every four to five days a Travis County resident takes his or her own life. Suicides in Travis County totaled 84, representing a suicide rate of 12.7 per 100,000 and a decrease of 11% from 1993. Males account for approximately 80% of suicides in Travis County in 1994 (Texas Department of Health, 1994)
  • No national data on attempted suicide are available; reliable scientific research, however, has found that there are an estimated 8-25 attempted suicides to one completion. The ratio is higher in women and youth and lower in men and the elderly

  Figure 4.8.9	Figure 4.8.10

  National research has found that people commit suicide because their problems seem overwhelming (i.e. no solutions or change is in sight, attempts to deal with problems fail or backfire.) Most suicides and suicide attempts are reactions to intense feelings of loneliness, worthlessness, helplessness, depression, etc. Depression and hopelessness are a leading cause of suicide. Depression may be caused by a personal loss, genetics or body chemistry. Major life changes, such as loss of an important person or job, or the heat of anger and frustration can lead people to attempt suicide before they have a chance to reconsider their decision. The prospect of increasing pain and suffering, loss of independence, income and dignity may trigger suicidal feelings. Use of alcohol or other drugs can weaken a persons self-control and lead to suicide attempts and self-destructive behavior.

  Certain groups have special problems that can cause suicidal feelings. Some young adults (including college students) become angry or stop caring about things they cannot change. Some young people feel socially isolated, for example, due to rejection by their peers and others because of their sexual orientation. For the elderly, loneliness is an especially serious burden. Illness and financial hardship contribute to the problem. Among professionals and successful business people, feelings of bitterness or disappointment, being cut off from their families, and unbearable pressure are factors that result in suicide. For minorities, cultural differences, poor economic, social and family conditions often lead to severe problems.

  In general, more women than men attempt suicide, but more men actually kill themselves. Women often use poison to commit suicide, whereas men are more likely to use a quick, violent means, such as a gun or hanging. Suicide tends to be more common as people get older.

  It is very difficult to track and measure the exact number of attempted suicides. There is currently no clear definition of attempted suicide. Part of the problem lies in the uncertainty as to whether a person attempted suicide or engaged in a self-mutilating act.

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  D. OTHER KEY OUTCOMES AND STATUS

  The Community Guide identified additional outcomes and consultations along with contributions from key groups. These outcomes are listed below with annotations that include clarification, availability of data, and recommendations for further use.

  The following outcomes are being addressed in other chapters:

  • Increased number of adults who feel safe in their communities (Public Safety)

  The following outcomes are measurable but do not have adequate data available:

  • Increased number of adults and their family members with the knowledge and skills to recognize risk factors of mental illness;
  • Increased number of adults who serve as positive role models;
  • Increased number of adults showing measured improvement in their mental health status and functioning;
  • Increased number of adults showing measured improvement in parenting knowledge and skills;
  • Increased number of adults who actively participate in community life.

  The following outcomes are difficult to measure and require the identification of an objective measure for each outcome in future meetings of the CAN:

  • Increased number of adults and their family members who receive information about available services;
  • Increased number of adults and their family members with the knowledge and skills to access mental health services;
  • Increased number of adults and their family members receiving and reporting they have received appropriate and comprehensive mental health services; and
  • Increased number of adults showing measured improvement in mental health status and functioning.

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