State Mental Health Agencies Research Articles

Effects of Texas State Agency Integration on Mental Health Service Use Among Individuals with Co-occurring Cognitive Disabilities and Mental Health Conditions.

This study uses Texas's 2017 integration of the state disability and mental health agencies as a case study, combining interviews with Texas agency and advocacy organization leaders to examine perceptions of agency integration and augmented synthetic control analyses of 2014-2020 Medical Expenditure Panel Survey to examine impacts on mental health service use among individuals with co-occurring cognitive disabilities (including intellectual and developmental disabilities) and mental health conditions. Interviewees described the intensive process of agency integration and identified primarily positive (e.g., decreased administrative burden) impacts of integration. Quantitative analyses indicated no effects of integration on receipt of mental health-related services among people with co-occurring conditions. While leaders identified some potentially beneficial impacts of state agency integration, the limited impact of integration beyond the agency suggests that interventions at multiple levels of the service system, including those targeting providers, are needed to better meet the mental health service needs for this population.

Availability of Medications for Opioid Use Disorder in Community Mental Health Facilities

Medications for opioid use disorder (MOUD) are an effective but underutilized treatment. Opioid use disorder prevalence is high among people receiving treatment in community outpatient mental health treatment facilities (MHTFs), but MHTFs are understudied as an MOUD access point. To quantify availability of MOUD at community outpatient MHTFs in high-burden states as well as characteristics associated with offering MOUD. This cross-sectional study performed a phone survey between April and July 2023 among a representative sample of community outpatient MHTFs within 20 states most affected by the opioid crisis, including all Certified Community Behavioral Health Centers (CCBHCs). Participants were staff at 450 surveyed community outpatient MHTFs in 20 states in the US. MOUD availability. A multivariable logistic regression was fit to assess associations of facility, county, and state-level characteristics with offering MOUD. Surveys with staff from 450 community outpatient MHTFs (152 CCBHCs and 298 non-CCBHCs) in 20 states were analyzed. Weighted estimates found that 34% (95% CI, 29%-39%) of MHTFs offered MOUD in these states. Facility-level factors associated with increased odds of offering MOUD were: self-reporting being a CCBHC (odds ratio [OR], 2.11 [95% CI, 1.08-4.11]), providing integrated mental and substance use disorder treatment (OR, 5.21 [95% CI, 2.44-11.14), having a specialized treatment program for clients with co-occurring mental and substance use disorders (OR, 2.25 [95% CI, 1.14-4.43), offering housing services (OR, 2.54 [95% CI, 1.43-4.51]), and laboratory testing (OR, 2.15 [95% CI, 1.12-4.12]). Facilities that accepted state-financed health insurance plans other than Medicaid as a form of payment had increased odds of offering MOUD (OR, 1.95 [95% CI, 1.01-3.76]) and facilities that accepted state mental health agency funds had reduced odds (OR, 0.43 [95% CI, 0.19-0.99]). In this study of 450 community outpatient MHTFs in 20 high-burden states, approximately one-third offered MOUD. These results suggest that further study is needed to report MOUD uptake, either through increased prescribing at all clinics or through effective referral models.

State Policies that Impact the Design of Children's Mental Health Services: A Modified Delphi Study.

To identify the state-level policies and policy domains that state policymakers and advocates perceive as most important for positively impacting the use of children’s mental health services (CMHS). We used a modified Delphi technique (i.e., two rounds of questionnaires and an interview) during Spring 2021 to elicit perceptions among state mental health agency officials and advocates (n = 28) from twelve states on state policies that impact the use of CMHS. Participants rated a list of pre-specified policies on a 7-point Likert scale (1 = not important, 7 = extremely important) in the following policy domains: insurance coverage and limits, mental health services, school and social. Participants added nine policies to the initial list of 24 policies. The “school” policy domain was perceived as the most important, while the “social” policy domain was perceived as the least important after the first questionnaire and the second most important policy domain after the second questionnaire. The individual policies perceived as most important were school-based mental health services, state mental health parity, and Medicaid reimbursement rates. Key stakeholders in CMHS should leverage this group of policies to understand the current policy landscape in their state and to identify gaps in policy domains and potential policy opportunities to create a more comprehensive system to address children’s mental health from a holistic, evidence-based policymaking perspective.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10488-022-01201-6.

The Social Determinants of Mental Health: A Descriptive Study of State Mental Health Agencies' Priorities.

Social determinants are receiving renewed attention as research demonstrates the effects of social factors on individuals’ physical and mental health and elucidates the biological and psychological mechanisms underlying those effects. Through spheres of influence from policy and regulation development to direct service provision, state mental health agencies are in a unique position to lead primary and secondary prevention efforts aimed at addressing social determinants with both client-level and structural-level interventions. A survey of social determinants-related activity was sent to the Medical Directors of the state offices of mental health in all 50 states. The survey results suggest consensus among respondents as to the importance of addressing specific social determinants. However, few state mental health agencies have taken on a comprehensive and intentional approach to addressing social determinants as a unique area of activity. Specific activities are reviewed, and implications for future work is discussed.

The Impact of Increasing Community-Directed State Mental Health Agency Expenditures on Violent Crime.

Violent crime remains a prevalent threat to population health within the United States. States offer varying policy approaches to prevent violent crime and support behavioral health, such as community-based programs that include substance use disorder prevention and treatment. Using state mental health agency data, we construct a panel of U.S. states over nine years and apply an instrumental variables empirical model with state and time fixed effects to adjust for policy endogeneity, omitted variable bias, and time trends. We find that a 10% increase in community-directed state mental health agency expenditures yielded nearly a 4% reduction in violent crime rates. Larger magnitude reductions in violent crime rates were associated with the presence of gun control regulations and increases in the proportion of the population completing secondary education. Policymakers should consider the added benefit of violent crime reduction when considering budgetary allocations of community-directed state mental health agency expenditures.

Growth of IPS Supported Employment Programs in the United States: An Update.

Individual placement and support (IPS), an evidence-based supported employment practice, is a core service in community mental health in the United States. Several factors promote the growth of IPS, including a network of 24 states participating in a learning community devoted to expanding IPS services. This study examined growth of IPS in the United States from 2016 to 2019, comparing growth rates for states within and outside the learning community. This national survey included telephone interviews with 70 representatives from state mental health and vocational rehabilitation agencies in 50 states and the District of Columbia, replicating methods of a 2016 survey. The primary outcomes were the number of IPS programs and clients served. The survey inquired about four indicators of state-level support for IPS implementation and sustainment: collaboration between state agencies, independent fidelity reviews, technical assistance and training, and funding. In 2019, 41 (80%) of 50 states and the District of Columbia had IPS services, with 857 IPS programs serving an estimated 43,209 clients. Between 2016 and 2019, the number of programs increased from 272 to 486 in 22 learning-community states and two learning-community counties, and from 251 to 371 in 18 states outside the learning community. State-level support for IPS was significantly greater in learning-community states, compared with non-learning-community states. IPS services expanded substantially in the United States between 2016 and 2019. Learning-community states had more rapid growth and provided greater implementation support, facilitating implementation, expansion, and sustainment of high-fidelity IPS. Nevertheless, access to IPS remains limited.

Impacts of COVID-19 on Mental Health Safety Net Services for Youths: A National Survey of Agency Officials.

Mental health agencies provide critical safety net services for youths. No research has assessed impacts of the COVID-19 pandemic on services these agencies provide or youths they serve. This study sought to characterize agency officials' perceptions of the pandemic's impacts on youths and challenges to providing youth services during the pandemic and to examine associations between these challenges and impacts. Surveys were completed in September-October 2020 by 159 state or county mental health agency officials from 46 states. Respondents used 7-point scales (higher rating indicated more severe impact or challenge) to rate the pandemic's impact on youth mental health issues, general service challenges, and telepsychiatry service challenges across patient, provider, and financing domains. Multiple linear regression models estimated associations between service challenges (independent variables) and pandemic impacts (dependent variables). Most agency officials perceived the pandemic as having disproportionately negative mental health impacts on socially disadvantaged youths (serious impact, 72%; mean rating=5.85). Only 15% (mean=4.29) perceived the pandemic as having a seriously negative impact on receipt of needed youth services. Serious service challenges were related to youths' lack of reliable equipment or Internet access for telepsychiatry services (serious challenge, 59%; mean=5.47) and the inability to provide some services remotely (serious challenge, 42%, mean=4.72). In regression models, the inability to provide some services remotely was significantly (p≤0.01) associated with three of five pandemic impacts. Officials perceived the COVID-19 pandemic as exacerbating youth mental health disparities but as not having a dramatic impact on receipt of needed services.

Academic-Policy Partnerships in Evidence-Based Practice Implementation and Policy Maker Use of Child Mental Health Research.

Strategies are needed to improve policy makers' evidence-informed decision making and the availability of evidence-based, state-supported services. This study examined whether academic-policy partnerships could promote these outcomes. Data from two national surveys of state mental health agency representatives were used to compare barriers to implementation of evidence-based practices (EBPs) and policy makers' use of child mental health research in states with strong academic-policy partnerships in workforce training or in program implementation/evaluation (IE) with barriers in states with no or limited partnerships in these areas. Strong IE partnerships were associated with more confidence in research use and fewer issues with provider readiness and capacity but with more issues with EBP fidelity. Strong training partnerships were associated with fewer endorsements of lack of time as a barrier to research use. Academic-policy partnerships had some benefit for states' research use and EBP implementation. Because these partnerships may reduce barriers, further research should explore characteristics of effective collaborations.

Developing Regional Mental Health Priorities: Mixed-Methods Needs Assessment of Eight States in the Southeastern United States.

State mental health agencies (SMHAs), which provide a variety of services to meet their residents' mental health needs, typically work within their own state, with little opportunity for cross-state collaboration and information exchange. This column describes a mixed-methods needs assessment conducted by the Southeast Mental Health Technology Transfer Center (MHTTC) to identify regional mental health priorities in eight states of the southeastern United States. The six priority areas identified were mental health workforce, school-based mental health, suicide prevention, peer workforce, criminal justice and mental health, and supported housing. These regional priorities inform the Southeast MHTTC's activities and can be used to promote collaborative exchange and problem solving among SMHAs.

Highest‐paid Missouri state employees revealed

Nearly all of Missouri's 25 highest‐paid employees work for the state's mental health agency, according to 2019 salary data from the Missouri government, the St. Louis Business Journal reported Oct. 6. Except for Missouri HealthNet director Todd Richardson, the state's highest‐paid employees are all in the Department of Mental Health. Nineteen of them are psychiatrists, one is a staff physician specialist, three are medical administrators and one is a special assistant official and administrator. Dr. Sekhar Vangala, a psychiatrist in Farmington, is once again the state's highest‐paid employee, with 2019 compensation of $418,569. He earned roughly the same amount in 2018. Gov. Mike Parson earned $133,821 in 2019. The office of the governor, which employed 51 people in 2019, had the highest average pay per person, at $43,883. The agency with the lowest average pay was agriculture, at $12,095 per person. For all 75,233 state employees, the average salary was $28,173 and the median was $27,566.

A Tale of Four States: Factors Influencing the Statewide Adoption of IPS.

Evidence-based supported employment has become a core community mental health service in much of the U.S. Although a national learning community has facilitated progress in about half of the states, other states have tried to implement evidence-based supported employment on their own. Many studies have examined site-level factors influencing implementation of supported employment, but few have focused on the role of state agency policies and actions. This study examined four states that have not joined the learning community, comparing two that have implemented with success (adopting states) and two that have faced challenges (non-adopting states). This comparative case study approach compared barriers, facilitators, and strategies in two states adopting IPS to two states that did not. The authors examined quantitative data from public records and conducted content analysis of qualitative and quantitative data from key informant interviews. The two non-adopting states lacked model clarity, funding, focus on people with serious mental illness, and collaboration between state mental health and vocational rehabilitation agencies. The two successful states experienced similar barriers but overcame them following lawsuit settlements that required implementation of evidence-based supported employment. Key strategies for successful implementation were funding, fidelity monitoring, technical assistance, and collaboration between state mental health and vocational rehabilitation agencies. With legal settlements serving as the catalyst, states facing challenges to implementing evidence-based supported employment can achieve success using standard implementation strategies to fund and ensure the quality of services.

The Impact of School Environment and Grade Level on Student Delinquency: A Multilevel Modeling Approach

Effects on delinquency made by grade level, school type (based on grade levels accommodated), and prosocial school climate were assessed, controlling for individual-level risk and protective factors. Data were obtained from the Substance Abuse Services Division of Alabama’s state mental health agency and analyzed via hierarchical linear modeling, yielding three major findings. First, grade level’s effects on delinquency varied strongly by school type, although in the multivariate context the interaction effects of grade level and school type were not significant. Second, prosocial school climate significantly explained differential delinquency rates. Third, the requirement that students change schools upon reaching a certain grade level does, as the literature notes, appear to lead to a poor environmental fit for students’ developmental needs.

The Relationship Between State Mental Health Agency and Medicaid Spending with Outcomes.

Little is known about relationships between state mental health expenditures and outcomes. This analysis evaluated relationships between spending and income across the states and mental health outcomes. Relationships between state per capita SMHA and Medicaid mental health spending, as well as median household income, percent of residents on Medicaid and Mental Health America (MHA) ranking, suicide and incarceration rates were assessed using correlations and multiple regressions. Median household income predicted MHA overall and youth ranking. Per capita Medicaid mental health spending predicted MHA prevalence ranking. Median household income and Medicaid spending predicted access to care ranking and incarcerations. Median income, Medicaid spending and percent receiving Medicaid predicted suicide rate. The findings suggest median household income may, in some cases, predict mental health treatment quality and outcomes more strongly than spending. However, the relationship with per capita mental health Medicaid spending on outcomes is also noteworthy.

Changes in Proportions of Emergency Department Patients with Mental Illness Noted in the National Hospital Ambulatory Medical Care Survey, 2012-2015.

The primary objective of this study was to determine whether there was a change in the rate and types of patients with psychiatric illnesses being seen in the emergency department (ED) from 2012 to 2015 using the National Ambulatory Care Survey. A secondary objective was to determine what if any changes occurred in the resources available to care for these patients. Our study used 2012-2015 data from the National Hospital Ambulatory Medical Care Survey and the State Mental Health Agency Per Capita Mental Health Services Expenditures, and expenditures data from 2012-2015 to examine whether there was a significant change in the rate and type of mental illness ED visits. Additional data on the number of beds per region from the National Mental Health Services Survey, 2012-2015 were used. A t test was used to look for significant (P = 0.05) changes in the rate and types of patients, ED dispositions, ED reimbursement types, region and community level income, sex, age, state mental health funding, and psychiatric beds from 2012 to 2015. There was an 8% increase in the rate of patients who presented with a diagnosed mental health disorder (P = 0.03, 95% confidence interval [CI] 5.32-5.96) and substance use disorders (P = 0.03, 95% CI 0.564-0.122). The reimbursement for these visits did change (P = 0.01, 95% CI 0.245-0.685); however, there was no significant increase (P = 0.07, 95% CI-214 to 101) in state mental health budgets and the number of psychiatric and detox hospital beds from 2012 to 2015. The rate and types of mental health patients coming to the ED are still on the rise. This is coupled with a lack of mental health infrastructure to address the needs and diagnoses that continue to be seen in the ED. States may need increased, targeted funding for mental health outside the increase in coverage via the Patient Protection and Affordable Care Act to slow the rate of mental health patients seen in the ED.

State mental health agency officials' preferences for and sources of behavioral health research.

State mental health agencies (SMHAs) are integral to public behavioral health service systems. As such, senior-level officials within SMHAs are important targets for advocacy and dissemination of behavioral health research findings. Evidence-informed decision making in SMHAs can potentially be enhanced by developing summaries of behavioral health research (e.g., policy briefs) that reflect SMHA officials' information preferences, but knowledge about these preferences is lacking. An exploratory study was conducted with the aims of characterizing senior-level SMHA officials' preferences for behavioral health research and describing where they turn for this research when making policy decisions. A cross-sectional, web-based survey of senior-level SMHA officials (1 per state) was conducted in March-May 2017 (n = 43, response rate = 84%). The features of behavioral health research that SMHA officials identified as "very important" most frequently were research being relevant to state residents (93.0%), providing data on cost-effectiveness (86.0%) and budget impact (81.4%), and being presented concisely (81.0%). The primary sources that SMHA officials turned to for behavioral research when making policy decisions were professional organizations (79.1%), SMHA agency staff (60.5%), and university researchers (55.8%). Compared with state legislators' responses to the same survey questions, results suggest that senior-level SMHA officials and legislators have similar preferences for behavioral health research but turn to different sources for this research. Advocates and researchers who seek to promote evidence-informed decision making in SMHAs should consider developing policy briefs that are concise, provide state-level prevalence data about behavioral conditions, and contain economic evaluation data, and they should disseminate these materials to multiple sources. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Selection of a Child Clinical Outcome Measure for Statewide Use in Publicly Funded Outpatient Mental Health Programs.

This study describes the process of choosing a clinical outcome measure for a statewide performance outcome system for children receiving publicly funded mental health services in California. The recommendation is based on a five-phase approach, including an environmental scan of measures used by state mental health agencies; a statewide provider survey; a scientific literature review; a modified Delphi panel; and final rating of candidate measures by using nine minimum criteria informed by stakeholder priorities, scientific evidence, and state statute. Only 10 states reported use of at least one standardized measure for outcome measurement. In California, the most frequently reported measures were the Child and Adolescent Needs and Strengths (CANS) (N=33), the Child Behavior Checklist (N=14), and the Eyberg Child Behavior Inventory (N=12). Based on modified Delphi panel ratings, only the Achenbach System of Empirically Based Assessment, the Strengths and Difficulties Questionnaire, and the Pediatric Symptom Checklist (PSC) were rated on average in the high-equivocal to high range on effective care, scientific acceptability, usability, feasibility, and overall utility. The PSC met all nine minimum criteria for recommendation for statewide use. In its final decision, the California Department of Health Care Services mandated use of the PSC and CANS. There is a lack of capacity to compare child clinical outcomes across states and California counties. Frequently used outcome measures were often not supported by scientific evidence or Delphi panel ratings. Policy action is needed to promote the selection of a common clinical outcome measure and measurement methodology for children receiving publicly funded mental health care.

Inter-Agency Strategies Used by State Mental Health Agencies to Assist with Federal Behavioral Health Parity Implementation.

State mental health agencies have potential to enhance implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA), particularly through collaborations with state insurance agencies. Little research, however, has examined state agencies’ MHPAEA implementation strategies. The study purpose was to describe the trend in collaboration between state mental health agencies and other state agencies to assist with MHPAEA implementation between 2010–2015 and characterize implementation strategies used. A content analysis of information in the State Mental Health Profiling System was conducted. In 2010, 54.9% of state mental health agencies anticipated involvement with MHPAEA implementation through collaborations with other state agencies, but only 23.5% were involved in 2012 and 11.8% were in 2015. Ongoing consultation (58.5%) and local technical assistance (14.6%) were the implementation strategies most frequently used. State mental health agency involvement with MHPAEA implementation though inter-agency collaboration has been limited. Future research should examine factors that influence such collaborations.

Adoption of the National CLAS Standards by State Mental Health Agencies: A Nationwide Policy Analysis.

This study reports the extent to which states have adopted the national culturally and linguistically appropriate services (CLAS) standards. Officials from public mental health agencies in the 50 states, Washington, D.C., and Puerto Rico were contacted between January and June 2016 to obtain information about adoption of CLAS standards in current policies. Each policy was coded through thematic analysis to determine its correspondence with any of the 14 national CLAS standards, which are grouped into three domains. Officials from 47 states and territories (90%) responded. Eight states (17%) reported adopting all national CLAS standards. Ten (23%) had adopted no CLAS policies, five (12%) had adopted policies under one domain, three (7%) under two domains, and 25 (58%) under all three domains. Most states do not have policies that meet all CLAS standards, raising questions about how CLAS standards should be adopted.

Availability of Mental Health Services for Individuals Who Are Deaf or Deaf-Blind.

A survey of state mental health agencies found that a majority have no specific policy or procedure regarding how to provide mental health services to persons who are deaf or who are deaf-blind. Agency representatives report that staff lack knowledge of how to provide mental health services to persons who are deaf-blind and the agencies lack qualified interpreters. They recommend training for social workers and counselors to address best practices in working with people who are deaf-blind concerning communication methods and strategies, physical interaction, cultural issues, everyday life, sensory deprivation, ethics, use of an interpreter, and other general issues.

The Dangers of Psychotropic Medication for Mentally Ill Children: Where is the Child's Voice in Consenting to Medication? An Empirical Study

When a child with a mental illness is being prescribed psychotropic medication. who decides whether the child should take the medication -- the parent or the child? What if the child is sixteen years of age? What if the child is in foster care: Should the parent or social service agency decide? Prior to administering psychotropic medication, what specific information should be provided to the person authorized to consent on behalf of the child? Should children be permitted to refuse psychotropic medications? If so, at what age should a child he able to refuse such medication What procedures should be put in place to forcibly medicate a child with psychotropic medication? There are numerous reports indicating that children in foster care are overmedicated as compared to children not in foster care. What are the reasons for this occurrence? Are there abuses within the foster care system? Should the state mental health agency monitor psychotropic medications for children, require oversight or a second opinion, or monitor abuse? What authority should a state agency have to stop prescribing psychotropic medication to children? This article will explore the overmedication of children with mental illness, with a specific emphasis on foster care children. Part I will examine the use of psychotropic medication on children, from the viewpoint of psychiatrists, pediatricians, parents, and children. Part II will explore the reasons why foster children receive psychotropic medications at a higher rate than children under their parents' care. Part IIl will provide an explanation of the consent procedures for children, and a critical inquiry into the manner psychiatrists and psychiatric hospitals undertake to address a minor's refusal to take psychotropic medication. Additionally, Part I will analyze various states' responses to addressing both the overmedicating of children as well as consent and refusal issues that ultimate]y result from the medication of children. It will offer recommendations for a model consent form to be utilized by psychiatrists and in-patient psychiatric hospitals. It will present the rights of children to refuse psychotropic medication as recommended and the procedure for overriding such refusal. Finally, Part III will analyze a survey of psychiatrists and pediatricians on the use of psychotropic medications to understand the existing consent procedures governing a minor's refusal to take psychotropic medications. The survey's design allows for a better understanding of the reasons behind the overmedication of foster children. The analysis will highlight the best practices and offer recommendations that provide for a state reporting and monitoring system.