1. Serious Psychological Distress and Stigma in Massachusetts DMH Partners Barbara Leadholm, M.S., M.B.A. DMH Commissioner Mary Ellen Foti, M.D. Connie Maranto Beth Lucas Kristen Roy-Bujnowski, MA DPH Partners John Auerbach. M.B.A. DPH Commissioner Bruce Cohen, Ph.D. Elena Hawk, Ph.D.

2. Project Background BRFSS: Behavioral Risk Factor Surveillance Survey Collaboration between the Massachusetts Departments of Mental and Public Health Supported by the Centers for Disease Control (CDC) and SAMHSA The 2007 Kessler 6 (K-6), Stigma, and Mental Health treatment report

3. What is the BRFSS? The BRFSS is an on-going, random digit-dial telephone health questionnaire of adults 18 years and older (A Nationally representative sample) that has been in use for 24 years. Jointly conducted by the Center for Disease Control (CDC) and all state health departments, the District of Columbia, Puerto Rico, Guam, and the Virgin Islands. Used to identify emerging health problems, establish and track health objectives, and develop and evaluate public health policies and programs.

4. BRFSS Components The Questionnaire collects information* about: – Chronic diseases – Injuries – Preventable infectious diseases – Health care access The BRFSS collects 7 out of the 10 leading health indicators identified by Healthy People 2010 Physical ActivityOverweight & Obesity Tobacco UseResponsible Sexual Behavior Mental Health Injury & Violence Access to Health Care (Substance Abuse, Immunization, and Environmental Quality are the other three) The Questionnaire contains: ▫ A core set of questions ▫ Optional additional CDC modules ▫ Optional questions added by individual states

5. How the Massachusetts Department of Public Health uses the BRFSS To provide data for reporting the health of Massachusetts residents compared to the U.S. population. To support the development of policies and recommendations for tobacco control. To assess the burden of disability in Massachusetts. To provide information to the Bureau of Substance Abuse and the MA Tobacco Control Program To provide data to the HIV/AIDS Bureau to inform needle exchange program policy To provide information regarding the availability of flu vaccinations To evaluate the effectiveness of various public health programs; ex. the Teen Pregnancy Prevention Program, the Diabetes Awareness Program To assess the health issues of Hispanic residents in Massachusetts during 1997-2001. To estimate the intake of calcium supplements in Massachusetts women

6. CDC Population Mental Health Surveillance The CDC is using two psychological measures for population mental health surveillance: The Patient Health Questionnaire (PHQ-8) and the Kessler 6 (K/6). ▫ The modules are implemented on alternating years.

7. What is the PHQ-8? 2006 & 2008 PHQ-8: The Patient Health Questionnaire¹ Self report survey about emotions or behaviors associated with depression experienced over a two week period* Valid in detecting depression in the general population¹ Culturally sensitive² Score ranges from 0-24 ( or the total number of days an emotion/behavior is experienced over a two week period) The score is converted to a point scale based upon CDC developed algorithms Kroenke K, Spitzer RL, & Williams JBW.(2001) The PHQ-9 Validity of a brief depression severity measure. Journal of General Internal Medicine ¹Kroenke K, Spitzer RL, & Williams JBW.(2001) The PHQ-9 Validity of a brief depression severity measure. Journal of General Internal Medicine 16 (9), 606-613. ² Huang FY, Chung H, Kroenke K, Delucchi KL, & Spitzer RL (2006) Using the Patient Health Questionnaire- 9 to Measure Depression among Racially and Ethnically Diverse Primary Care Patients Journal of General Internal Medicine 21 (6), 547–552.

8. What is the K-6¹? 2007 & 2009 The Kessler 6 (K-6) is a screening instrument for non-specific psychological distress Contains six questions measuring symptoms over a one month period A score of 13 or greater indicates serious psychological distress (SPD) ▫ Provides estimates of mental health disorders in a population, such as mood and anxiety ¹ Kessler, R. C. et al (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, Vol 32(6):959-976.

9. Stigma and Mental Health Treatment 2007 & 2009 Additional questions about stigma and mental health treatment were added to the K/6 module ▫ Stigma is a public health issue because people may be in denial of symptoms, avoid screening or discourage others from being screened, and untreated symptoms can become worse.¹ ¹ Kobau, R. (2007). Assessment of Mental Illness Stigma--Behavioral Risk Factor Surveillance System. Presentation at the K6 Workgroup Conference call. CDC Division of Adult & Community Health SAMHSA Center for Mental Health Services.

10. 2007 Project Goals and Structure The K-6, Stigma, and Mental Health Treatment questions : Provide state prevalence estimates on serious psychological distress Identify relationships between serious psychological distress (SPD), chronic conditions & behavioral risk factors Provide state prevalence estimates on stigma Provide state prevalence estimates on mental health treatment The Project Structure In Massachusetts Initiated by SAMHSA to facilitate collaboration between states’ departments of mental and public health DMH provided data analysis, psychiatric consultation, quality review and infrastructure support DPH provided raw data, consultation, and on-going statistical analysis support

11. Analyses BRFSS respondent answers are weighted using Massachusetts population estimates to produce statewide prevalence rates We examined relationships between self-reported serious psychological distress and: ▫ Drinking, Smoking, Obesity & Exercise ▫ Stroke, Cardiovascular Disease & Diabetes ▫ Employment ▫ Health care access ▫ Suicide ▫ Racial disparities

12. Massachusetts Prevalence of SPD An estimated 3.1% (approximately 155,000) of the adult Massachusetts Population has serious psychological distress**

13. Prevalence of SPD by Gender

14. Prevalence of SPD by Age

15. Prevalence of SPD by Race/Ethnicity *Significant at the p<.05 level

16. Prevalence of SPD by Martial Status *Significant at the p<.05 level

17. Prevalence of SPD by Education *Significant at the p<.05 level

18. Prevalence of SPD by Employment Status *Significant at the p<.05 level

19. Prevalence of SPD by Health Care Access *Significant at the p<.05 level

20. Prevalence of SPD by Chronic Health Conditions *Significant at the p<.05 level

21. Prevalence of SPD by Health Behaviors *Significant at the p<.05 level

22. Quality of Life Indicators by Serious Psychological Distress *Significant at the p<.05 level

23. Treatment can help people with mental illness lead normal lives

24. People are generally caring and sympathetic to people with mental illness

25. Prevalence of Mental Health Treatment by Gender *Significant at the p<.05 level

26. Prevalence of Mental Health Treatment by Age

27. Prevalence of Mental Health Treatment by Race/Ethnicity

28. Prevalence of Mental Health Treatment by Marital Status *Significant at the p<.05 level

29. Prevalence of Mental Health Treatment by Education

30. Prevalence of Mental Health Treatment by Employment *Significant at the p<.05 level

31. Prevalence of Mental Health Treatment by Veteran Status

32. Prevalence of Mental Health Treatment by Health Care Access *Significant at the p<.05 level

33. Summary: Who has the highest prevalence rates of SPD in Massachusetts? Hispanics have the highest prevalence rates of SPD and it is statistically significant when compared to White, non- Hispanics. Those with less than a High School degree. People who have been previously married or never married. Those who are unable to work or are currently unemployed. Those who were unable to see a physician due to cost. People with chronic heart disease, diabetes, and asthma. People who are current smokers, do not exercise, are obese, and participate in binge drinking.

34. Summary: Stigma and Massachusetts Most people in Massachusetts agreed strongly that treatment can help people with mental illness lead normal lives. Respondents agreed slightly that people are generally caring and sympathetic towards those with a mental illness.

35. Summary: Who received mental health treatment in Massachusetts during 2007? Females Those who have been previously married or never married. Those who are unable to work or are currently unemployed. Those who needed to see a doctor but were unable to due to cost.

36. Summary The K/6 and PHQ-8 The K/6 and PHQ-8 two different mental health issues: non-specific psychological distress and depression ▫ The PHQ-8, an estimated 7.9% of the Massachusetts population had diagnosable depression ▫ The K/6, 3.1%, of the population reported SPD

37. Summary The K/6 and PHQ-8 Adults aged 18-25 reported the highest rates of depression (15%) 25-34 year olds had the highest rates of SPD ▫ This is interesting in that National data reports high SPD rates for 18-25 (17.9%)* Non-Hispanic Blacks reported the highest rates of depression in 2006 (15.4%) Hispanics had the highest rates of SPD (9.1%) *2007 National Survey on Drug Use & Health (NSDUH) Data, SAMHSA; http://oas.samhsa.gov/nsduh/2k7nsduh/2k7results.pdf http://oas.samhsa.gov/nsduh/2k7nsduh/2k7results.pdf

38. Summary The K/6 and PHQ-8 Despite the different mental health issues, similar significant patterns of chronic health issues and lifestyle behaviors were found.

39. Both measures demonstrate that persons who are/have Unemployed (PHQ-8: 25.8%; K6: 7.2%) Current smokers (PHQ-8: 14.1%; K6: 7.7%) Obese (PHQ-8: 13.4%; K6: 6.2%) Diabetes (PHQ-8: 13.7%; K6: 8.5%) Were unable to see a doctor when needed due to cost (PHQ-8: 26.5%; K6:10.5%) ▫ Have higher rates of a mental health issues ▫ These results illustrate the ongoing need to recognize the relationship between physical and emotional health in chronic conditions.

40. Next Steps Distribute to Secretary Bigby and to the heads of the other Health and Human Agencies Continue joint collaborations regarding future analyses of psychiatric/behavioral health modules included in MA BRFSS questionnaires. Include recommendations to state agencies on identification and prevention of depression within the general population.