Mary Jane Alexander, PhD.Deborah Layman, MA

Gary Haugland, MA

Nathan Kline Institute for Psychiatric Research

APHA 141st Annual Conference November 4, 2013

Mary Jane Alexander

No relationships to disclose

The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

NYS Office of Temporary Disability Assistance

NYS Office of Mental Health MH078188 to Dr. Alexander

Why an MH screen – and why the MMS - in Local Social Service Settings?

MMS Study in NYS Local Social Service Departments

Policy considerations

• Full and diverse community participation is a human rights principle and a public policy goal

• Increased % of public assistance benefit recipients with complicating conditions that affect quality of life

• Presence of MH Conditions in LSSDs is around 50%

• About 40% of those who met criteria for any MH condition in 2011 did not receive services

• Some evidence for supported approaches to Employment

Authors Lifetime (L) Current (C) Population

Kessler (2005) 46.4% 26.2% General Household Survey

Alexander & Haugland (2008) 43% Substance Use Treatment

Bassuk (1998)MD 44%; PTSD 35%

AFDC Single Moms

Cook (2009)61% (Any)53 % MH

TANF single Moms

Huan & Douglas (2004) 30%TANF single parents, 6 states

Shinn & Alexander(2003) 43%TANF new applicants

Current StudyAlexander, Layman, Haugland, Tang (2012)

64% (Any) 38% (Any) Current Study in NYS

52% (MH) 36% (MH)

MH Conditions among PA MH Conditions among PA recipientsrecipients

Free

Brief (22 items)

Easy to use and score

Computer based administration and scoring available

Comprehensive (mood, anxiety, and psychosis)

Excludes substance use (already screened by OTDA)

Validated in NYS in Chemical Dependency OP & residential

settings, street outreach programs, jails and shelters and

now in local social service departments.

1. Understand the extent of MH conditions and functioning among NYS beneficiaries

2. Validate the Modified Mini Screen (MMS) using the SCID

3. Develop decision rules for MH referrals

LSSDs: 5 counties volunteered to host the study

COUNTIES 7 of NY State’s 10 Largest Cities (excluding NYC)

Westchester Yonkers, Mt. Vernon, White Plains, Portchester

Monroe Rochester

Albany Albany

Erie Buffalo

Rensselaer

In each site all clients appearing to recertify public assistance benefits were invited to participate

Informed consent was obtained from people who were interested in participating

Participants were compensated $25 for completing the screen and $50 for completing the telephone diagnostic interview

1) Brief, computer assisted interview:

MMS, background, health questions (N= 517)

2) Telephone interview:

SCID for DSM-IV (N= 476)

%

Female 74

Race & Ethnicity

Black 63

White 23

Hispanic 13

American Indian 5

Other 11

Education

No diploma 39

High School or similar 35

Some college/Advanced 27

Age (Mean and sd) 37 years (11)

%

Relationships & Parenting

Participant:

Is a Parent 88

Lives with Some Children 62

Has Ever Been Married/In Marriage-Like Relationship

30

Is Currently Married/In Marriage-Like Relationship

23

Case Type (n=490)

Family Assistance 34

Safety Net Families 25

Safety Net Individuals 41

MMS

Chronbach’s alpha .9

Test –retest .7 Mean (sd) T1 = 7 (6); T2 = 5 (5)

SCID

Inter-rater reliability

Any Lifetime Diagnosis 1.0

Any Current Diagnosis 0.91

Anxiety 0.91

Major Depression 0.83

PTSD 0.82

SCID Diagnosis StatusLifetime Current

n % n %

Any 313 (64%) 186 (38%)

Mental Health 255 (52%) 176 (36%)

Mood 201 (41%) 96 (20%)

Anxiety 178 (36%) 138 (28%)

Psychotic 20 (4%) 14 (3.0%)

Lifetime and Current Rates of Lifetime and Current Rates of MH ConditionsMH Conditions

Health and FunctionNo Current Diagnosis

MH CurrentDiagnosis

Mean (SD) Mean (SD)

MMS Average 5.4 (5.2) 12.9 (4.9)GAF 74.8 (9.8) 56.6 (10.5)

Physical Health 44.6(11.6) 40.7 (12.4)

Mental Health 48.6(11.5) 34.9 (10.0)

Unable to carry out usual activities (days)

5.8 (8.3) 11.7 (8.3)

In bed due to illness or injury (days)

3.2 (6.0) 6.8 (8.0)

Health and Functioning

FA n=166

SNIn=199

SNFn=125

TotalN=490

Mean SD Mean SD Mean SD Mean SD

MMS Score 6.9(5.8) 9.4(6.6) 7.4(6.0) 8.1(6.3)

GAF 70.6(12.3) 65.5(14.1) 69.7(12.5) 68.3(13.3)

Physical Health Measure

45.5 (11.5) 39.5 (12.3) 45.8 (11.1) 43.1 (12.0)

Mental Health Measure

44.1 (12.3) 42.2 (13.0) 45.4 (13.0) 43.7 (12.8)

Days unable to carry out usual activities

6.3 (7.8) 10 (9.6) 6.6 (8.0) 7.9 (8.2)

Days in bed due to illness or injury

3.5 (6.2) 5.9 (8) 3.6 (5.9) 4.5 (7.0)

Functioning by Case Type Functioning by Case Type

Over 1/3rd of our sample met criteria for Current MH condition

Over 60% of our sample met criteria for Lifetime MH condition

All participants reported lower levels of functioning than the general population

Participants with a Current MH condition reported poorer health and functioning than participants with No MH condition

Safety Net Individuals and older participants reported poorer health and functioning and higher rates of all MH conditions than TANF and Safety Net Families

Over a lifetime, mood disorders were most common (41% of all participants)

In the past month, anxiety disorders were the most common (28% of all participants)

269 (55%) participants experienced a traumatic event in their lifetime

65 (13%) percent met criteria for PTSD in their lifetime

Treatment Histories

MH Lifetime (N=255)

MH Current (N=176)

N % N %

No Lifetime MH Treatment

57 22% 36 20%

No Current MH Treatment

91 36% 77 44%

Matrix of Accuracy With a cutoff of 7-9

MMS OF 7 OR MORE53% Referred

MMS OF 8 OR MORE48% Referred

MMS OF 9 OR MORE

43% Referred

True MH Diagnosis

No MH Diagnosis

True MH Diagnosis

No MH Diagnosis

True MH Diagnosis

No MH Diagnosis

# Above 7 162 97 # Above 8 151 83 # Above 9 142 71

# Below 7 14 217 # Below 8 25 231 # Below 9 34 243

Accuracy

True Positive

Rate

93%

False Positive

Rate

31%Accuracy

True Positive

Rate

86%

False Positive

Rate

26%Accuracy

True Positive

Rate

81%

False Positive

Rate

23%

The MMS is a reliable and accurate screen for use in Local Social Service Departments

Best “statistical” balance between true and false positives occurs between MMS scores 7-9

Decision rules should be based on local capacity

Screen should be optional for localities

Screen should be optional for individuals

NKI Center to Study Recovery in Social Contexts. Adapted from Sen