The Intersection Between Mental Health & School Based Health Centers Marsha Broussard, DrPH, MPH Samantha Francois, PhD Louisiana School-Based Health Alliance Conference April 14, 2015

Presenter Disclosures Marsha Broussard, DrPh, MPH & Samantha Francois, PhD (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No Relationships to disclose.

Presentation objectives Why Do we Care? To describe School Health Connections motivation and path for prioritizing this work To provide an overview for our School Based Health Center Impact Evaluation and review major findings To describe and obtain input on responses to the study findings

Background Evaluation of WKKF Post-Katrina funding focused on re- developing and expanding School Based Health Center (SBHC) in the Greater New Orleans Area Assumptions: SBHC services would increase access to care for a very vulnerable population. SBHC services would play a role in addressing high risk behaviors among a highly -traumatized population SBHC’s integrated care model, emphasizing integrated physical and emotional /behavioral services, would have a high level of impact on students Two cross sectional analysis, 2009 & 2012, were conducted, comparing self-reported data from students attending schools with and without SBHCs

2009 SBHC Impact Study Findings Over 28 % of students reported general symptoms of depression Females, 32.8%; males 21.3% Suicide ideation Percentages are higher for females and younger ages SBHC schools associated with greater mental health care access SBHC schools associated with lower risky behaviors SBHC schools associated with some lower violence-related risk behaviors Students more likely to have ever met with a behavioral health counselor, (29.8% vs. 23.0%, p = 0.001 ) Students with suicidal ideation were 8% more likely to have seen a behavioral health counselor Students more likely to have talked with a behavioral health counselor within the last 12 months, (16.5% vs. 11.6%; p = 0.002) Students 16 % more likely to have been treated for a behavioral health issue by a school clinic or nurse, (39.3% v. 23.4%; p < 0.001) Students less likely to have drunk alcohol, (60.1% vs. 70.5%; p < 0.001) Students less likely to have smoked marijuana, (28.0 % vs. 38.3%; p < 0.001) Less likely to have had sex, (53.5% vs. 60.5%; p = 0.002) More likely to have been tested for an STD, (28.5% vs. 24.0%; p = 0.072) Sexually active students in SBHC schools were less likely to be using contraception, (31.4% vs. 35.9%; p = 0.041) Students in SBHC schools were less likely to carry a weapon in the past 30 days, (12.6 % vs. 16.7 %; p = 0.009). 30.5 % of students attending SBHC schools had been in a fight vs. 37.6% of students without a SBHC, p = 0.001.

2012 Study Questions Are students from schools with SBHCs associated with reporting increased access to comprehensive preventive and primary care Are SBHCs associated with decrease use of higher cost alternatives to care, such as emergency room use. Are SBHCs associated with decreased high risk behaviors among adolescents Are SBHCs associated with positive health habits (Improved dietary habits, Higher physical activity levels.)

2012 SBHC Impact Study Methodology 2012 Cross sectional analysis, quasi-experimental Nine Orleans Parish High Schools 6 with and 3 without SBHCs Questions based upon YRBS N = 3,125 students Main Study Goal: Assess the effectiveness of SBHCs in increasing access to and utilization of essential health services and promotion of healthy life-styles and good decision- making.

2012 Sample Sizes by School

Operational Status of SBHCs in 2009 and 2012 Schools 2009 2012 O. Perry Walker FT McMain Warren Easton * PT Cohen McDonogh #35 N/A Science and Math Sarah T. Reed Karr Carver * = No SBHC N/A = School did not participate

Focus of this Presentation

Contextual Factors Post – Katrina New Orleans High child poverty rate, associated with poor physical and mental health outcomes High rate of community violent crime High rate of community of child abuse and neglect High rates special education needs students Learning disabilities, emotional disabilities, mental retardation

Prevalence of depression and suicide ideation Overall, 30.3% of surveyed students reported symptoms of depression within the last 12 months. More female students reported depressive symptoms than male students (38.1% vs. 20.5%, p=0.0001 respectively). There was no statistically significant difference in the percentage of students who reported depression when comparing all SBHC schools (30.6%) with non-SBHC schools (29.5%) (p=0.53). However, schools with SBHCs that were established before 2009 had a higher percentage of students who reported depression (34.5%) than schools with SBHCs that opened after 2009 (27.4%). This finding suggests that established SBHCs may have developed and informed a culture in those schools around seeking care for emotional concerns. Overall, of 13.5% of students reported having seriously considered suicide within the last 12 months and 10.6% reported having made a plan to commit suicide. Suicide ideation in the last 12 months was reported by more female than male students (p=0.0001).  The percentage of students who considered suicide was highest at SBHC schools. The percentage of students who reported making a suicide plan was greatest at SBHC schools that were established before 2009 (13.3%) and lowest among students at SBHC schools that opened after 2009 (9.2%).  

Depressive Symptoms and High Risk Behaviors and Experiences Depressive symptoms were higher among boys who reported violence-related behaviors and experiences (p<0.01). Similarly, more boys who reported these behaviors and experiences than boys who did not have these experiences indicated that they had received behavioral health counseling, had been treated with medication for a behavioral health issue, and had seen a health care provider about a drug or alcohol problem (p<0.001).  

Risk Behaviors

SBHC schools associated with less cigarette smoking on school property Nearly 17% of students in the study sample reported ever smoking an entire cigarette. The only statistically significant difference was found for the percentage of students reporting recent smoking on school property. Whereas 3.4% of SBHC students reported recent smoking at school, 5.8% of students at non-SBHC schools reported this behavior (p=0.002).

Cigarette Smoking and Sex Differences Significantly more male students reported greater cigarette smoking than female students.

Alcohol Consumption and Presence of SBHC No difference between the percent of SBHC and non-SBHC school students who reported having ever or recently (last 12 months) drank alcohol nor for binge drinking. Greater percent of SBHC school students reported drinking alcohol on school property than non-SBHC school students (8.5% vs. 5.0%, p<0.0001). Among the study sample, 61.4% of students reported ever consuming at least one alcoholic beverage and 35.2% said they had recently consumed alcohol (within the last 30 days). These percentages were similar to national estimates from the 2013 YRBS (66.2% for ever consumption and 34.9% for recent consumption).

Alcohol Consumption and Sex Differences Ever and recent alcohol consumption were both greater among female students (65.8% and 38.6%, respectively) than male students (55.8% and 30.8%, respectively). These differences were statistically significant (p<0.0001). More male than female students reported drinking alcohol on school property, (7.3% vs. 4.9%, p=0.005). Binge drinking was greater among male students (13.8%) than female students (11.8%), but this difference was not significant (p=0.09).

SBHC schools associated with less marijuana use on school property No difference between SBHC and non-SBHC students reported use of marijuana. Use of marijuana on school property was reported more frequently among students attending schools without a SBHC (11.0%) than students attending schools with a SBHC (7.0%, p<0.0001). Among 2012 SHC Impact Survey respondents, 40.2% of students reported having ever used marijuana, which is similar to the national average of 40.7%.

Marijuana Use and Sex Differences More male students reported having ever used marijuana than female students (45.5% vs. 35.8%, p<0.0001). More male students reported use of marijuana before the age of 13 years than female students (p<0.0001).

Marijuana Use Similar to national data, use of marijuana was common among students participating in the 2012 SHC SBHC Impact Survey. Research supports a strong relationship between illicit drug use and youth violence. Furthermore, drug use has been associated with mental health and behavioral health issues among adolescents. While use of illicit drugs may contribute to mental and behavioral health problems, drugs may also be used by adolescents to cope with mood disorders and negative feelings. SHC data revealed that among boys who reported recent marijuana use, 39.4% also experienced depressive symptoms. Just 30.1% of male students who reported that they had not used marijuana in the last 30 days reported that they had depressive symptoms (p=0.004). Similar to other high risk behaviors, the frequencies of treatment for a behavioral health issue, treatment with medication for a behavioral health issue, and seeing a health care provider about a drug or alcohol problem were higher among boys who recently used marijuana than among boys who did not use the drug (p<0.0001).   Office of Applied Statistics, Substance Abuse and Mental Health Services Administration. (2006). The National Survey on Drug Use and Health: youth violence and illicit drug use. Rockville, MD. National Institute on Drug Abuse. Marijuana. 2014. www.drugabuse.gov Accessed September 16, 2014.

Violence and Bullying

Violence Exposure among Orleans Parish School Youth

SBHC schools associated with less violence exposure Although 13.7% of students in the Impact Survey reported having carried a weapon in the past 30 days, this percentage was less than the national average of 17.9%. Nearly 6% of students (5.4%) reported that they carried a weapon at school in the past 30 days, a percentage that was comparable to the national average (5.2%). Carrying a weapon was also more frequent among students who attended schools without a SBHC. 12% of SBHC students said they carried a weapon in the past 30 days compared with 17.3% of students who attended schools without a SBHC (p<0.0001). 7.2% of students at non-SBHC schools carried a weapon on school property compared with just 4.6% of SBHC students (p=0.003). Nearly 11% of students attending non-SBHC schools reported having missed school due to safety concerns whereas 8.6% of SBHC students said they missed school for this reason in the past 30 days (p=0.04). Similarly, being threatened with or injured by a weapon at school was reported by more non-SBHC students (12.9%) than SBHC students (9.4%, p=0.003). Fewer students attending SBHC schools reported being in or being injured in a physical fight (31.6% and 6.2%, respectively) when compared to students attending non-SBHC schools (36.9% and 8.4%, respectively).

Violence exposure by sex Males report greater exposure to violence than females on the majority of indicators. Carrying a weapon and carrying a weapon at school were reported by 8.8% and 3.8% of female students, respectively and were reported by 19.8% and 7.3% of male students. More male students than female students said they had been threatened with or injured by a weapon (13.2% vs. 8.3%, p<0.0001). More male students said they had been in a physical fight and been injured in a physical fight (37.5% and 9.0%, respectively) than female students (29.8% and 4.9%, respectively). More male students reported dating violence than female students (15.1% vs. 10.2%, p<0.0001).

Violence-related Behaviors and Experiences Compared with national data for adolescent males, frequencies for several violence-related behaviors and experiences were higher among male students who completed the 2012 SHC SBHC Impact Survey (Figure 2). Missing school due to concerns about safety at school or on the way to school, having been threatened with or injured by a weapon at school, and having been in a physical fight were all more frequent among male students in the SHC SBHC Impact Survey sample.

School Performance and High Risk Behaviors and Experiences In addition to an association with high risk behaviors, the presence of mental and behavioral health issues among adolescents has been associated with poor school performance1,2. Data for male students from the 2012 SHC SBHC Impact Survey revealed that 7.8% of boys who had depressive symptoms and 4.5% of boys who did not have depressive symptoms mostly earned grades that were lower than a “C” (Figure 5). This difference was not statistically significant. However, the frequency of mostly earning grades that were lower than a “C” was higher among boys who had high risk experiences compared with boys who did not have high risk behaviors or experiences.  

SBHC schools associated with less bullying on school property Based on 2013 national YRBS data, approximately one in five U.S. adolescents reported being bullied within the past year. With respect to SBHC status and sex, there were no statistically significant differences in the percentages of students who reported having been bullied in the past year. Bullying other students in the last 12 months differed by SBHC status. Overall, 10.5% of students said they had bullied someone else on school property in the past year. The percentage was higher among non-SBHC students (12.8%) than SBHC students (9.5%, p=0.006). A marginally statistically significant difference was found for the comparison of SBHC students (9.6%) and non-SBHC students (11.8%) who reported that they had been bullied using technology (p=0.07).      The only notable sex difference in bullying was the percentage of female students reporting that they had been bullied electronically (11.9%) was greater than the percentage of male students who reported this experience (8.1%, p<0.0001).

Mental and Behavioral Health Care Access

SBHC schools associated with greater MBH care access More SBHC school students report talking with a behavioral health counselor than non-SBHC school students (40.5% vs. 29.5%, p<0.0001). More SBHC school students reported talking with a behavioral health counselor in the last 12 months than non- SBHC school students (25.6% v. 15.6%, p<0.0001). SBHC utilization data showed 20% of all visits were behavioral health visits. Compared with students at non-SBHC schools, considerably more students attending schools with a SBHC that was established before 2009 reported talking with a behavioral health counselor (40.5% vs. 29.5%, p<0.0001). Similarly, more students attending SBHCs that opened before 2009 reported that they talked with a behavioral health counselor in the last 12 months than non-SBHC students (25.6% vs. 15.6%, p<0.0001). The percentage of students who reported ever talking with a behavioral health counselor and talking with a counselor in the last 12 months at SBHC schools that opened after 2009 were similar to the proportions of students who reported these experiences at non-SBHC schools. In addition, among students who reported that they had talked with a behavioral health professional, students who attended SBHC schools that opened after 2009 and those who attended non-SBHC schools reported that they made fewer visits to talk with a behavioral health counselor than students at schools with a SBHC that opened before 2009 (p<0.0001). Utilization data from each SBHC echoed this trend. Overall, behavioral health visits represented about 20% of all visit types that school year and, similar to the Impact Survey results, more visits were reported at schools with SBHCs that were established prior to 2009.

Primary source of MBH counseling services School social workers were a primary source of behavioral counseling for students at all schools. However, students at schools with a SBHC utilized behavioral counseling services at the SBHC more than students at non-SBHC schools. More students at non-SBHC schools than SBHC schools reported seeking behavioral health services at community clinics and hospitals.

Study Implications SBHCs are a viable option for supporting vulnerable populations such as urban youth. African American males are an especially vulnerable population, reporting more risk behaviors and exposure to more violence, and SBHCs have access to this population SBHCs can play a critical role in supporting students efforts to complete high school through reducing risk of suspension and drop out. Further analyses are needed to compare drop out and suspension rates in study schools would support this inference

Next Steps for School Health Connection Support SBHCs in conducting more effective outreach to students with mental and behavioral health needs. Provide special focus on recruitment of AA males to SBHCs for behavioral and mental health services. Educate school leaders on the benefits of having SBHCs on campus.

What do you Think? Discussion, Questions Contact Information: Marsha Broussard, DrPH (mbroussard@lphi.org) Samantha Francois, PhD (sfrancois@lphi.org)