1. Mary Jane Alexander, PhD. Deborah Layman, MA Gary Haugland, MA Nathan Kline Institute for Psychiatric Research APHA 141 st Annual Conference November 4, 2013

2. 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:

3.  NYS Office of Temporary Disability Assistance  NYS Office of Mental Health   MH078188 to Dr. Alexander

4.  Why an MH screen – and why the MMS - in Local Social Service Settings?  MMS Study in NYS Local Social Service Departments  Policy considerations

6. 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

7. 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 Study Alexander, Layman, Haugland, Tang (2012) 64% (Any)38% (Any) Current Study in NYS 52% (MH)36% (MH) MH Conditions among PA recipients

8.  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.

10. 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

11. LSSDs: 5 counties volunteered to host the study COUNTIES7 of NY State’s 10 Largest Cities (excluding NYC) WestchesterYonkers, Mt. Vernon, White Plains, Portchester MonroeRochester Albany ErieBuffalo Rensselaer

12.  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

13. 1) Brief, computer assisted interview: MMS, background, health questions (N= 517) 2) Telephone interview:  SCID for DSM-IV (N= 476)

14. % Female74 Race & Ethnicity Black63 White23 Hispanic13 American Indian5 Other11 Education No diploma39 High School or similar35 Some college/Advanced27 Age (Mean and sd)37 years (11)

15. % Relationships & Parenting Participant: Is a Parent88 Lives with Some Children62 Has Ever Been Married/In Marriage-Like Relationship 30 Is Currently Married/In Marriage-Like Relationship 23 Case Type (n=490) Family Assistance34 Safety Net Families25 Safety Net Individuals41

16. MMS Chronbach’s alpha.9 Test –retest.7 Mean (sd) T 1 = 7 (6); T 2 = 5 (5) SCID Inter-rater reliability Any Lifetime Diagnosis1.0 Any Current Diagnosis0.91 Anxiety0.91 Major Depression0.83 PTSD0.82

18. SCID Diagnosis Status LifetimeCurrent n%n% Any 313(64%)186(38%) Mental Health255(52%)176(36%) Mood201(41%)96(20%) Anxiety178(36%)138(28%) Psychotic20(4%)14(3.0%) Lifetime and Current Rates of MH Conditions

19. Health and Function No Current Diagnosis MH Current Diagnosis Mean (SD) MMS Average5.4 (5.2)12.9 (4.9) GAF74.8 (9.8)56.6 (10.5) Physical Health44.6(11.6)40.7 (12.4) Mental Health48.6(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)

20. Health and Functioning FA n=166 SNI n=199 SNF n=125 Total N=490 MeanSDMeanSDMeanSDMeanSD MMS Score6.9(5.8)9.4(6.6)7.4(6.0)8.1(6.3) GAF70.6(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

21.  Over 1/3 rd 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

22.  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

23. Treatment Histories MH Lifetime (N=255)MH Current (N=176) N%N% No Lifetime MH Treatment 5722%3620% No Current MH Treatment 9136%7744%

26. Matrix of Accuracy With a cutoff of 7-9 MMS OF 7 OR MORE 53% Referred MMS OF 8 OR MORE 48% 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 16297 # Above 8 15183 # Above 9 14271 # Below 7 14217 # Below 8 25231 # Below 9 34243 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%

28.  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

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