Access to Mental Health Services Among Patients at Health Centers and Factors Associated with Unmet Needs

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1 Access to Mental Health Services Among Patients at Health Centers and Factors Associated with Unmet Needs Emily Jones, Lydie A. Lebrun-Harris, Alek Sripipatana, Quyen Ngo-Metzger Journal of Health Care for the Poor and Underserved, Volume 25, Number 1, February 2014, pp (Article) Published by Johns Hopkins University Press DOI: For additional information about this article Accessed 4 Apr :01 GMT

2 ORIGINAL PAPER Access to Mental Health Services Among Patients at Health Centers and Factors Associated with Unmet Needs Emily Jones, PhD, MPP Lydie A. Lebrun- Harris, PhD, MPH Alek Sripipatana, PhD, MPH Quyen Ngo- Metzger, MD, MPH Abstract: Cross- sectional 2009 Health Center Patient Survey data describe the mental health status of health center patients, utilization of mental health services, and factors associated with unmet need for mental health treatment. One in five health center patients accessed mental health services in the past year, and over half of the patients who received counseling received this treatment at a health center. Patients who were unable to access mental health care cited affordability as a concern. Unmet need for mental health treatment was reported by one in three patients. Multivariate analysis found that the odds of reporting unmet need were higher for patients who lacked a usual source of care and patients with serious mental illness. Key words: Access to care, disparities, mental health, primary care, underserved populations, health center. About half of the United States (U.S.) population will experience a mental health condition in their lifetime, 1 and major depression is the leading cause of disability. 2 Effective, evidence- based treatments for mental health issues exist, but many factors lead to undiagnosed cases and unmet need for treatment services. In 2005, 5.7 million adults reported an unmet need for mental health care and did not gain access to treatment in the previous year. 3 Average delays in identification and treatment can span six to eight years for mood disorders and nine to 23 years for anxiety disorders. 4 Unmet need for mental health care disproportionally affects disadvantaged communities and populations who face poverty, 4,5,6 low educational attainment, 7 lack of health insurance, 4,5,6 racial minority status, 4 severity of mental health issues, 4 medical comorbidities, 5 and other barriers to accessing mental health care. 2,8 Among adults who report unmet need for mental health services, almost half report that cost and insurance issues are major barriers to accessing treatment. 3 In addition, the lack of a At the time this article was written, all of the authors were affiliated with the Office of Quality and Data, Bureau of Primary Health Care, Health Resources and Services Administration, United States Department of Health and Human Services; Rockville, Maryland. Please address correspondence to Emily Jones, PhD, MPP at emilybjones@gmail.com. Meharry Medical College Journal of Health Care for the Poor and Underserved 25 (2014):

3 426 Access to mental health services usual source of care is associated with delays in access to mental health services. 7 This echoes the finding that patients who lack a usual source of care are more likely than others to have unmet need for medical services. 9 The primary care visit is an opportunity to identify and treat underlying mental health issues. 10 The primary care system is a portal of access to mental health treatment, since patients often present medical symptoms associated with mental health needs to their primary care providers. 2 Overall, more than 40% of patients with mental health problems seek care in the primary care setting. 11 Federally qualified health centers constitute one of the largest primary care systems in the United States, providing care to over 20 million patients in underserved communities without regard to the patient s insurance status or ability to pay in In addition to primary care services, over four out of five health centers provide mental health services on site; these services could be prescriptions, therapy, or both. 13 In 2011, health centers employed 4,486 mental health specialists, including 1,394 licensed clinical social workers, 403 licensed clinical psychologists, and 401 psychiatrists. 14 Behavioral health capacity is rising in health centers, as a result of both an overall increase in health center capacity and an increase in the proportion of health centers offering mental health treatment services. 15 A series of Mental Health and Substance Abuse Service Expansion Grants accelerated this capacity increase; by 2003, 26% of health centers had received an expansion grant. 16 Treating patients mental health needs in a health center has been found to increase rates of mental health treatment initiation and engagement among health center patients. 17 A survey of medical directors in community health centers found that 80% identify cost as the main barrier that prevents their uninsured patients from accessing appropriate behavioral health services. 18 However, the prevalence of unmet need for mental health services among health center patients has not been documented to date, and the correlates of unmet need have not been explored with patient- level data. The main objectives of this study were to explore the mental health needs of health center patients, the utilization of mental health services, and correlates of unmet need for mental health services. This study explores whether the trends in the literature on correlates of unmet need for mental health services also apply among health center patients, and adds to the literature on the association between having a usual source of care and access to mental health care. We hypothesized that lacking a usual source of care would be associated with unmet need for mental health services, even after accounting for potential confounding by sociodemographic characteristics. The 2009 Health Center Patient Survey, which has previously been used to examine substance use disorders 19 but not mental health, provides a unique patient- level data source that is nationally representative of health center patients. Methods Research design. This cross- sectional study used the 2009 Health Center Patient Survey to describe the mental health status of health center patients, the utilization of mental health services, and the factors associated with unmet need for mental health services. Descriptive statistics summarizing the responses to the mental health- related

4 Jones, Lebrun-Harris, Sripipatana, and Ngo-Metzger 427 survey questions were explored, and the correlates of unmet need were explored using bivariate and multivariate logistic regression models. The 2009 Health Center Patient Survey was fielded to obtain information from patients of health centers that receive funding from the Health Resources and Services Administration. 20 The survey captured information regarding sociodemographic characteristics, health conditions, health behaviors, access to and utilization of health care services, and satisfaction with the care received. The survey was fielded using a three- stage sample design. First, 188 health center organizations were sampled, stratified by funding stream, health center size, region, urban/ rural location, and number of care delivery sites per health center organization. Then, 432 eligible care delivery sites were identified, with up to three sites per health center organization sampled. Finally, in the third stage, 23 to 30 patients from each site who were served at least once during the lookback year were sampled, yielding a total of 4,562 patient interviews between September and December Patients belonging to special populations, such as homeless patients, were oversampled. For this analysis, data from patients aged 18 and over were used (n = 3,949). Dependent variables. Unmet need for mental health care was defined as either a delay or an inability to access mental health care that the patient or a doctor thought was necessary in the last 12 months. Covariates. Selection of independent variables for the model was informed by the literature on factors associated with unmet need for mental health care. The access model served as the conceptual framework for this study. The model specifies three domains of factors that influence whether an individual accesses health care: predisposing, need, and enabling. 21 In this study, predisposing demographic traits were examined, need was accounted for by severity of mental illness, and enabling factors such as insurance status and having a usual source of care were included. The multivariate model was fit based on the bivariate results and observing the change in indices of goodness of fit when different variables were added and omitted from the model during an iterative process. The multivariate logistic regression model was adjusted for region as well as the following self- reported patient characteristics: age (continuous), gender, race/ ethnicity (non- Hispanic Black, Hispanic, and non- Hispanic non- Black, which consists of the non- Hispanic White and other categories combined), educational attainment (high school/ GED or greater versus less than high school/ GED), insurance status (insured or uninsured, collapsed from the detailed insurance status information in Table 1), mental health status in the last month (serious mental illness or not), unmet need for medical care in the past year (yes or no), and whether the patient has a usual source of medical care (yes or no). To be included in the sample, all of the patients had accessed health care at a health center, by definition. Mental health status in the last month was measured using the Kessler Psychological Distress Scale, which has been validated in numerous countries and is frequently used in other U.S. health surveys to measure distress associated with depression and anxiety. 22 Serious mental illness is defined as a score equal to or greater than 13. Data analysis. Multivariate logistic regression was performed using Stata, version Due to the complex sampling design, weighting was applied during analysis. 20 Weighted data were nationally representative of patients served by federally qualified

5 428 Access to mental health services Table 1. DESCRIPTIVE STATISTICS Region West rtheast Midwest South Survey Respondents Weighted % (SE) (N = 3,949) (.07) (.05) (.06) (.07) Age (years) (.03) (.02) Over (.02) Gender Male (.03) Female (.03) Race/ Ethnicity n- Hispanic Black (.04) Hispanic (.04) n-hispanic, n-black (.04) Education High school diploma/ GED or greater Less than high school diploma/ GED (.03) (.03) Health insurance Uninsured (.03) Private (.02) Medicare 7.23 (.01) Medicaid (.03) Unmet need for medical care Usual Source of Care Source: 2009 Health Center Patient Survey (.02) (.02) (.03) (.02) health centers in terms of characteristics such as age, race/ ethnicity, poverty status, gender, and insurance status. Results Sample characteristics. The demographic characteristics of the sample are found in Table 1. Adult health center patients were racially and ethnically diverse, over 40% did

6 Jones, Lebrun-Harris, Sripipatana, and Ngo-Metzger 429 not have a high school diploma or GED, and 40% were uninsured. More than one in four patients (29.7%) reported experiencing an unmet need for medical care within the past year, and four in five patients (80%) reported that they have a usual source of care. Mental health status of health center patients. Half of adult health center patients reported suffering from depression at some point in their lives (51%, see Table 2). One in three reported problems with generalized anxiety (35%), and almost one in five patients reported having panic disorder (19%). About 12% of patients suffered from serious mental illness in the past 30 days, signified by a Kessler score of 13 or above. Over half of patients reported that their mental status had disrupted their normal activities at least somewhat in the past month. In the past year, 21% of adult patients were either told by a doctor or concluded themselves that they needed to see a mental health professional. Mental health care utilization. Utilization patterns of mental health treatment services mirrored self- reported needs among health center patients. Over one in five adult patients (21%) accessed mental health treatment or counseling in the past year (see Table 3). Adult patients who accessed treatment in the past year for mental health issues also indicated what type(s) of treatments they used. Individual counseling and prescription medications were the most common, with 68% of patients receiving individual counseling, and 60% receiving prescription medications. One in seven (16%) patients who used mental health services participated in group counseling, and almost as many (13%) utilized inpatient hospitalization or mental health facility services. Table 2. MENTAL HEALTH STATUS OF ADULT HEALTH CENTER PATIENTS, 2009, N = 3,949 Survey Respondents Weighted % (SE) Lifetime report of Depression Generalized Anxiety Panic Disorder Mental health status, past month (Kessler score) Serious mental illness (K6 13) Mental health status interfered with activities, past month A lot A little Somewhat t at all Needed mental health services, past year (.03) (.02) (.02) (.01) (.01) (.02) (.01) (.03) (.02) (.02) Source: 2009 Health Center Patient Survey.

7 430 Access to mental health services Table 3. MENTAL HEALTH TREATMENT UTILIZATION AMONG ADULT HEALTH CENTER PATIENTS, N = 3,949 Survey Respondents Weighted % (SE) Accessed mental health treatment/ counseling among all adult patients, past year Type of treatment received in past year, among patients who received treatment Individual counseling Group counseling Prescription medications Inpatient hospital/ mental health facility Accessed mental health counseling at a health center, among all adult patients who received individual or group counseling in the past year Referred by a health center to a community- based provider for mental health counseling, among all adult patients who received individual or group counseling in the past year and indicated that only some or none of their counseling was received at a health center Unmet need among patients who needed mental health services that the patient or doctor thought was necessary, past year a (.02) (.02) (.04) (.02) (.04) (.03) (.05) (.05) (.05) (.05) (.04) (.04) Source: 2009 Health Center Patient Survey. a Unmet need is a delay and/or an inability to access mental health services in the past 12 months, among adult patients who reported that they or a doctor thought they should receive counseling from a mental health professional (N = 1,031). Among adult health center patients who received individual or group counseling in the past year, over half (53%) received these services at a health center. Among health center patients who received counseling but did not exclusively receive these services at a health center, over one in three report that a health center referred them to the location where they received counseling (35%).

8 Jones, Lebrun-Harris, Sripipatana, and Ngo-Metzger 431 Unmet needs among health center patients who needed mental health treatment. Within the last year, one in three adult health center patients (32%) who needed mental health treatment services experienced unmet need for mental health care, defined as an inability to access mental health care that the patient or a doctor thought was necessary. The main reason behind these access difficulties was affordability: 39% of patients who were unable to access mental health care stated that they could not afford the care. Other barriers cited by patients include a lack of insurance coverage for mental health services (5%), a lack of time to seek services (13%), uncertainty regarding where to access care (10%), and embarrassment or discomfort about seeking help about mental health issues (14%). Other problems reported by less than 5% of patients included transportation and childcare challenges. Similar reasons were given by patients who needed treatment but experienced a delay in accessing mental health care. Factors associated with unmet need for mental health services. In the multivariate model, unmet need for mental health services among adult health center patients that needed mental health care was associated with region, having a usual source of care, and severity of mental health condition (see Table 4). Compared with those in the South, patients in the Midwest (OR or Odds Ratio =.22, 95% CI or Confidence Intervals = ), rtheast (OR =.31, 95% CI = ), and the West had lower predicted odds of unmet need (OR =.38, 95% CI = ). Compared with patients who lacked a usual source of care, patients with a usual source of care had lower odds of experiencing unmet need for mental health services (OR =.24, 95% CI = ). Patients with serious mental illness had greater odds of experiencing unmet needs for mental health care (OR = 1.87, 95% CI = ), compared with patients with less severe mental health needs. These patients might require more intensive services, leading to the increased likelihood of experiencing a delay or inability to access mental health services. Racial and ethnic differences in rates of unmet needs for mental health services were absent, as were disparities associated with age, gender, insurance status, and education level. Discussion Health centers provide access to mental health treatment in the primary care safety net, either on site or through referrals to community- based providers when services across the continuum of care are not available in health centers. The present study finds that one in five adult health center patients accessed mental health services from any provider in Over half of health center patients who received counseling services in 2009 received those services from a health center. One in three patients that needed mental health services reported unmet needs for mental health care, and affordability was the top reason for unmet needs, cited by 39% of these patients. In multivariate models, unmet need for mental health services was associated with lacking a usual source of care, serious mental illness, and being located in the South. The literature shows that health centers in the South are less likely to have on- site mental health services, and this study extends these findings and provides evidence that health center patients in the South are more likely to report unmet need. 16

9 432 Access to mental health services Table 4. UNMET NEED FOR MENTAL HEALTH SERVICES IN THE PAST 12 MONTHS, AMONG HEALTH CENTER PATIENTS OVER 18 (N = 730) Unmet Need Adjusted Odds Ratio (95% Confidence Intervals) Region West 0.38 ( )* rtheast 0.31 ( )** Midwest 0.22 ( )*** South (ref) Age 0.98 ( ) Gender Female 1.05 ( ) Male (ref) Race/ Ethnicity n- Hispanic Black 0.90 ( ) Hispanic 0.73 ( ) n-hispanic, n-black (ref) Education High school diploma/ GED or greater 1.28 ( ) Less than high school diploma/ GED (ref) Health Insurance Insured Uninsured (ref) 0.91 ( ) Mental health status Serious mental illness 1.87 ( )* serious mental illness (ref) Unmet need for medical care, past year 1.72 ( ) (ref) Usual Source of Care (ref) 0.24 ( )** Source: 2009 Health Center Patient Survey. *p <.05 **p <.01 *** p <.001 te: Model F-value = 5.36; probability of obtaining this F value if the coefficients of the independent variables were all zero =.000.

10 Jones, Lebrun-Harris, Sripipatana, and Ngo-Metzger 433 These results are consistent with previous research indicating that patients who do not have a usual source of care are more likely to experience a delay in access to mental health care. 11 While all of the patients included in the survey sample had been treated at a health center at least once to be eligible to be included in the sample, it is important to note that only four in five patients (80.4%) reported having a usual source of care. The concept of a usual source of care goes beyond point- in-time access, encompassing longitudinal stability in the location where the patient seeks medical care. The association between usual source of care and unmet mental health treatment needs highlights the potential role of longitudinal access to primary care as a precursor enabling access to appropriate mental health care. The finding that patients with more severe mental illness were more likely to experience unmet needs is also consistent with previous research. 2 It is important for health centers to maintain a referral network to ensure that connections to community- based behavioral health providers are available to patients who would benefit from a more intensive care setting, particularly for specialized services such as inpatient and emergency care. This study also echoes other studies that highlight the role of health centers in addressing disparities in access to care. 24,25,26 The absence of disparities in unmet need for mental health care based on race and ethnicity, gender, insurance status, and education level is notable since disparities based on these demographic attributes is well documented in other care settings. 4,5,6,7,8,9,10,11,12 Further research is needed to examine the role of health centers in addressing these disparities. A few limitations are notable, including the cross- sectional nature of the data which limits the ability to infer causation. The patient survey data are based on self- report, creating the opportunity for measurement error in the variables; this error might not be random, but rather associated with the demographic characteristics of patients. Recall bias might affect patient reports of unmet need for mental health care in the past year. Mental health status might be a sensitive topic for some patients and thus their answers might be subject to social desirability bias. In addition, the Kessler Psychological Distress Scale might not adequately detect psychosis or other mental health symptoms, since it was designed to explore depression and anxiety. Unmet need is only measured among patients who reported that they thought mental health counseling was necessary, so unmet need among patients who were not aware that they needed mental health services was likely undercounted by the survey. Since, in order to be included in the sample, all of the patients surveyed had accessed care at a health center, the percentage who report having a usual source of medical care is likely to overestimate the percentage of all residents of the United States that have a usual source of care. The results of this study are generalizable to adult health center patients, but not to children. Further research on the mechanisms driving unmet need for mental health services should explore the interactions between different risk factors. The staffing models used by health centers should also be examined in more detail, using qualitative methods, to expand knowledge of best practices in screening, treating, and referring patients with mental health needs. Finally, research to improve coordinated care in the so-called medical neighborhood, 27 with community- based mental health providers is needed, including

11 434 Access to mental health services how to maximize the effectiveness of health information technology, particularly for patients with serious mental illness. Key strategies for reducing unmet need among health center patients include expanding capacity of mental health specialists, building and strengthening linkages with behavioral health providers in the community, and training primary care staff on evidence- based screening practices for mental health issues. Support for learning collaboratives might improve the ability of health center providers to identify mental health needs and provide the appropriate referral. Depression was one of the key conditions targeted by the Health Disparities Collaboratives, an initiative launched in 2000 to improve clinical quality in health centers. That program ended, but health centers are involved with other learning collaboratives. 28 The barriers that prevent many individuals from getting adequate mental health treatment may loom even larger in underserved communities. While the absence of disparities based on other factors is a positive finding, there is room for improvement in reducing unmet need for mental health treatment among health center patients. This study provides evidence that some of the most vulnerable health center patients with mental health treatment needs those lacking a usual source of care and those with severe mental illness are the most likely to experience unmet mental health care needs. Acknowledgments Conflict of Interest: authors have a conflict of interest to report, financial or otherwise. tes 1. Kessler R, Berglund P, Demler O, et al. Lifetime prevalence and age- of-onset distributions of DSM- IV disorders in the National Co- Morbidity Survey Replication. Arch Gen Psychiatry Jun;62(6): dx.doi.org/ / archpsyc ; PMid: United States Public Health Service, Department of Health and Human Services. Mental Health: a report of the Surgeon General. Rockville, MD: United States Public Health Service, Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Results from the 2005 national survey on drug use and health: national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Wang P, Berglund P, Olfson M, et al. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry Jun;62(6): PMid: Roll JM, Kennedy J, Tran M, et al. Disparities in unmet need for mental health services in the United States, Psychiatr Serv Jan;64(1): dx.doi.org/ /appi.ps ; PMid: Baggett TP, O Connell JJ, Singer DE, et al. The unmet health care needs of homeless adults: a national study. Am J Public Health Jul;100(7): dx.doi.org/ /ajph ; PMid: PMCid:PMC Mojtabai R. Unmet need for treatment of major depression in the United States.

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