1. Need and Unmet Need of Mental Health among Community Dwelling Seniors In New York City Shijian Li, Ph.D. SUNY at Old Westbury William Gallo, Ph.D. CUNY School of Public Health and Graduate Center APHA, 2014

2. Presentation Outline  Literature review  Research question  Methods  Results  Discussion

3. Aging and Prevalence of Mental Illness  Greater percentage of lifespan spent in old age

4. Significances of the Problem: Mental Health Concerns Many old people are living with chronic illness, including mental illness, in their later years: ... not uncommon in late life (One in four older adults has a clinically significant mental disorder, exceeding 15 million by 2030 (Palinkas et al, 2007) ... often unreported ... often unrecognized ... related to loss of physical functioning and independence ... very treatable

5. Study Design (1): Research Questions 1. How prevalent were mental disorders (i.e. depression) among community dwelling older adults in NYC? 2. How often did older adults with mental disorder seek professional mental health service? 3. What were the predictors for using the professional mental health service among older adults?

6. Study Design (2): Data: 1. Health Indicators Project (HIP): Survey conducted in 2008 by the Brookdale Center for Healthy Aging & Longevity of Hunter College/City University of New York (CUNY) 2. Funded: NYC Mayor’s Office (through NYC Department for the Aging) 3. Sampling Stratified based on: 1) borough; 2) senior center size; 3) race/ethnicity. 4. Subject recruitment: systematic selection procedure.

7. Study Design (3): Final Sample Sample drawn from 56 senior centers  10 in the Bronx  16 in Brooklyn  13 in Manhattan  14 in Queens  3 in Staten Island. Final sample contains 1,870 older adults.

8. Theoretical Framework Health Behavior Model (Anderson, 1995)  Predisposing: predict the propensity of an individual to use healthcare (e.g. demographics, etc.)  Enabling: factors enable or impede health service use (e.g. SES, health insurance, healthcare services availability)  Need variables: perceived or evaluated need, representing the most immediate cause of health service use.

9. Measurement (1) Patient Health Questionnaire (PHQ-9): PHQ-9 scores of 5, 10, 15, and 20 represent valid thresholds demarcating the lower limits of mild, moderate, moderately severe, and severe depression. Mental healthcare utilization: whether having been to or used mental health professional (e.g. a psychiatrist, psychologist or social worker) in the last 12 months. (Yes/No). Unmet need: defined as in need of care (being mild to severe depression, 5<PHQ-9<27), but reporting no use of professional mental health services in the previous 12 months.

10. Measurement (2) Predisposing: Age, Gender, Marital Status, Religion attendance, Race/Ethnicity, Education attainment Enabling:  Personal (i.e. Income, Difficulty to meet Expenses, English ability, Accessibility, Social Support, Discrimination),  Community (i.e. Neighborhood cohesion, Neighborhood safety, Availability of medical clinic/health service in neighborhood) Need: Health Assessment (Physical Disability, ranging 0-7)

11. Descriptive Highlights Study Sample: 525 (28.1%) older adults mildly to severely depressed (PHQ9 score >=5) Among them: PHQ-9 Proportion % (SD) Mildly/Moderately Depressed (PHQ9 score: 5-14) 88.8(1.4) Moderately Severe/Severely Depressed (PHQ9 score: 15-27) 11.2(1.4) Mental Health Service Use in 12 months Yes 20.1(1.8) No 79.9(1.8)

12. Descriptive—Enabling & Need Factors Enabling Proportion % (SD) Expenses Extremely/somewhat Difficulty 45.6(2.2) Not all difficulty 54.4(2.2) Language at Home English 53.4(2.2) Other 46.6(2.2) Discrimination Experiences Yes 40.2(2.1) No 59.8(2.1) Medical service in neighborhood Yes 79.1(1.8) No 20.9(1.8) Need Factors Proportion % (SD Physical Disability No/mildly disabled (<4) 47.7(2.2) Disabled (4-7)52.3(2.2)

13. Multivariate Logistic Regression Analytic Strategy:  Multiple imputations: variables with missing values were accomplished by imputing 10 values for missing items with the user-written ICE command in Stata.  Hierarchical logistical regression: to examine the relative contribution of predisposing, enabling and need factors for mental health service use within the past 12 months.

14. Regression Results Model 1 a Model 2 b Model 3 c Characteristics (N=525) OR95% CIOR95% CIOR95% CI Predisposing Factors (ref.) Age (60-65) 66-740.640.35-1.200.690.36-1.300.660.35-1.27 75-840.220.11-0.440.230.11-0.480.220.10-0.46 85+0.110.04-0.300.130.05-0.340.110.04-0.30 Marital Status (Married/Partnered) 0.420.22-0.800.410.21-0.810.430.21-0.86 Religious Attendance (never) Monthly1.030.56-1.90.960.51-1.831.010.53-1.92 Weekly0.520.27-1.00.490.24-0.970.520.26-1.00 Education (<high School) High School 0.530.28-1.000.510.26-0.970.550.28-1.07 >High School 0.890.48-1.640.860.45-1.620.890.47-1.68 Need-for-care Factors Physical Disability (4-7 Disabilities)* 2.051.21-3.47 Notes: a. Model 1: predisposing factors b. Model 2: Predisposing factors + Enabling Factors c. Model 3: Predisposing factors + Enabling Factors + Need Factors d. NONE of any e nabling factors were significant (expenses, language at home, social support, discrimination, neighborhood cohesion, neighborhood safety, availability of health service in neighborhood)

15. Summary Only about 20% of those in need of mental health service actually received it in the past 12 months The older of Old Americans, the married, the better educated, and those attend religious service regularly are less likely to seek mental health service Individuals with worse physical health condition are more likely to utilize mental health service Interesting, none of the enabling factors, including financial resources, language, and social support, were significant predictors of service utilization.

16. Discussion Underserved Mental health for the older of the old Americans Age-appropriate mental services needed Primary Care as a potential location for mental health Connecting seniors to mental health resources may improve their lives.