the question: âOn average, how many days a month is your mental health not good?â Nationally, women report from a lo
Mental Health The detailed commentary and data are captured in separate sections for mental and physical health. If you wish to read both sections, proceed now with mental health. If you prefer, you can also start with or only read the physical health section.
Mental Health With the increased attention to mental health nationwide, and especially in Northeast Florida, more is known regarding the unique conditions of women’s mental health and what approaches are effective when working with women to become mentally healthy. The challenge is having those resources easily available and affordable. What follows is commentary and data about these topics: •
Women’s mental health conditions.
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Resources (mental/health systems, access/cost, mental health professionals).
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Unique needs and resources to address specific populations: women in the military and women veterans, girls, justice-involved women and girls.
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Stigma.
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Priorities for change: legislation and policy.
Women’s Mental Health Conditions Women have higher incidences than men of certain mental health conditions including anxiety, depression and eating disorders. Of particular note is the incidence of depression. The National Health and Nutrition Examination Survey, 2009-2012 reports the following: “Depression is associated with higher rates of chronic disease, increased health care utilization and impaired functioning. Females have higher rates of depression than males in every age group. “Additionally, •
Persons living below the poverty level were nearly two and a half times more likely to have depression than those at or above the poverty level.
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Non-Hispanic white persons were more likely to have no depressive symptoms than either non-Hispanic black persons or Hispanic persons.”
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As reported in the Institute of Women’s Policy Research 2015: Status of Women in the States: Health and Well-Being, the 2013 Behavioral Risk Factor Surveillance System uses one measure of the status of mental health in men and women. It asks the question: “On average, how many days a month is your mental health not good?” Nationally, women report from a low of 3.1 days to a high of 5.4 days per month (men report 3.3 days per month). Southern states all fare the worst on this indicator; in Florida, women report 4.7 days per month. Multiple factors contribute to the likelihood of women’s increased incidences of certain mental health conditions. Of particular importance are factors such as higher rates of poverty, challenging family demands and the experience of trauma. Trauma Trauma refers to extreme stress that overwhelms a person’s ability to cope. A person’s subjective experience determines whether an event is or is not traumatic. It could be a one-time event such as an accident, natural disaster, a death, sexual assault; or chronic or repetitive experiences such as neglect, child abuse, combat or relationship violence. The need to recognize the role trauma plays in behavioral health disorders (in mental illness and in substance abuse) is becoming better understood. Trauma is a near universal experience of people with behavioral health problems. According to the U.S. Department of Health and Human Services’ Office on Women’s Health report, •
55-99 percent of women in substance abuse treatment
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85-95 percent of women in the public mental health system
have a history of trauma, with the abuse most commonly having occurred in childhood. Substance Abuse The National Bureau of Economic Research reports a definite connection between mental illness and the use of addictive substances and that mental health disorders often are responsible for the consumption of alcohol, cocaine and cigarettes. “Women may face unique issues when it comes to substance abuse, in part influenced by difference in biology. In addition, women themselves describe unique reasons for using drugs, including controlling weight, fighting exhaustion, coping with pain, and self-treating mental health problems.” There also is evidence that women are more sensitive to the effects of some drugs. There is a clear link between trauma and drug use in women. The impact of failing to treat this combination of self-medication and trauma is particularly apparent among women who have experienced domestic violence and those in the justice system. Fortunately, there are effective, evidence-based approaches to address co-occurring trauma and substance abuse.
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Suicide For some people who live with severe mental illness, suicide is the final outcome. It is the tenth leading cause of death in the U.S. and the third leading cause for ages 15-24. The suicide rates are higher for older men than for older women. More Northeast Florida (and Florida) residents died of suicide in 2014 than from homicide. The chart captures the comparison of female death by homicide and suicide in Northeast Florida counties. There are several important observations about the data: •
The Florida rate of female suicide is 6.5 percent per 100,000 women compared to 5.4 percent per 100,000 nationally.
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Female suicide rates in Northeast Florida counties are even higher than statewide.
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Most references to gender differences and suicides indicate that females tend to consider suicide more frequently than do males; however, males tend to have higher suicide rates.
Mental Health Resources Building Coordinated, Affordable Mental Health Service Systems The Jacksonville Community Council, Inc., (JCCI) Fall 2014 report on community mental health in Northeast Florida notes: “Knowing when and how to access care as well as pay for the care is difficult and confusing.” While a very unwieldy mental health system presents challenges, some progress is occurring. Leading the efforts to build coordinated systems of care are: •
Jacksonville System of Care Initiative. Drawing on an initial $9 million federal grant plus a funding extension through 2019, the work is targeted to transform the mental health services for youth and children with serious emotional disturbances into an integrated system of care. The priority populations are homeless youth, children in subsidized day care, justice-involved youth and youth entering foster care.
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Among the many accomplishments since its beginning in 2010, here are a few of particular note: o
Made systemic changes for screening the targeted populations and providing referrals.
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Implemented wraparound care coordination.
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Piloted a Collaborative Care Model with 100 area pediatricians trained to screen, refer and/or treat adolescents with suicide or depressive symptoms.
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Implemented steps to ensure the involvement and influence of youth and parents in designing the system of care.
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o
Developed and supported a variety of critical training sessions for providers.
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Conducted capacity studies regarding child-serving clinicians and social services provided to children and youth.
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Florida’s Managing Entity System. The Department of Children and Families established the Managing Entity System, a regional model, to efficiently and effectively deliver behavioral health care to the uninsured. Florida Tax Watch’s recent report on the system notes that the approach is a good one, has made progress to achieve its original goals and that there is more to do—particularly giving the regional entities more flexibility in how they disburse funds to better meet the needs of the respective regions in the state.
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LSF Health System is the Managing Entity for 23 counties including the five Northeast Florida counties. Its work includes centralizing data, and encouraging and monitoring efficiency and effectiveness among providers. LSF has been awarded an additional $6.5 million for mental health and substance abuse services in the Northeast region for fiscal year 2015-2016.
Paying for Mental Health Services •
On-going treatment is expensive. Under the Affordable Care Act, insurers are required to include payment for mental health services; however, a large number of Americans remain uninsured.
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Medicare provides coverage, but many mental health professionals will not accept Medicare as the primary payment because reimbursement rates are low.
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Since Florida declined to expand Medicaid, people with incomes above the eligibility limit but below 133 percent of the poverty line have no coverage. Their only options for treatment are emergency departments and community-funded mental health agencies.
Availability and training of mental health professionals in Northeast Florida •
There is a significant need for more psychiatrists. Increasing the number of psychiatry residencies available in Florida would help fill some of the gap.
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Allowing Advanced Registered Nurse Practitioners to prescribe medications for behavioral health issues would increase patient access.
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While the number of mental health counselors in Northeast Florida is considered sufficient, non-profit service providers often cannot afford to hire them full-time. Some arrange for part-time professionals, supplemented by supervised internships for mental health professionals in training.
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Given the central role of trauma in behavioral health disorders, there is a need for more mental health professionals who are trained to provide gender-responsive, traumainformed counseling and more who are trained to provide counseling for co-occurring trauma and addiction.
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The JCCI’s Mental Health Report Implementation Team includes a subcommittee with a focus on integrating mental and physical healthcare. Included in the recommendations (2014 Mid-Term Highlights of JCCI Mental Health Implementation Project, unpublished): o
Cross train physical health professionals to recognize mental health indicators and to integrate mental and physical care. While LSF (the Managing Entity for Northeast Florida) provides an extensive training menu, too few physicians take
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advantage of these opportunities. A related recommendation is a hotline that primary care physicians could call when they have behavioral health questions. o
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Expand the use of telemedicine and specifically tele-psychiatry to help fill some of the gaps due to the insufficient number of psychiatrists. Florida Blue currently is the only payer that allows reimbursement.
Two programs from the National Council for Behavioral Health -- Youth Mental Health First Aid and Adult Mental Health First Aid – are effective resources for teaching skills for responding to signs of need, interacting with persons in need and taking appropriate next steps.
Unique Needs and Resources to Address Specific Populations The Justice System The former Duval County Sheriff, John Rutherford, commented frequently that the jails and prisons have become the default mental health system for those who have no other options. “Jails are not a therapeutic community. They are never going to be.” Yet in a one-year period 64 percent of local inmates have mental problems, 56.2 percent in state prisons and 44.8 percent in Federal prisons. The female population has a higher percentage of mental illness than males (Interview with Jacksonville Sheriff’s Office, 1/16/2016). The Jacksonville Criminal Justice and Behavioral Health Collaborative was formed with the support and direction of LSF in 2015 to work to create a system of care to address the needs of those who enter the Duval County justice system with mental health and substance abuse needs. The goal is to reduce the number with mental illness who are needlessly incarcerated and provide the necessary community resources to prevent them from additional contact with law enforcement. An important part of the initiative is the recent approval for a central receiving facility with hundreds of beds and the ability to have patients stay for as long as 90 days. The facility will treat people with mental illness with pre-trial mental health services; jail after-care; and SOAR processing. (SOAR refers to the service to assist those with mental illness to regain Social Security Income and Social Security Disability Income support when they have lost these benefits as a result of incarceration.) In Duval County about a third of those entering incarceration are female; however, many women are released due to a bond or plea agreement. Given the total pre-trial population of women and the fact that justice-involved women have a higher occurrence of mental illness than do men, it is likely that the new central receiving facility will need to be expanded to serve more women (Interview with Sheriff’s Jacksonville Sheriff’s Office, 1/16/2016). Public Schools Public school systems have an important role to play in recognizing behavioral health issues and providing support. Trained personnel in schools can aid in the early identification of child and adolescent depression and other conditions. Florida state law requires public schools to provide Individual Education Plans (IEPs) for certain students, but the fear of stigma causes some parents and physicians to be reluctant to recommend such plans.
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Full Service Schools (FSS) is a collaboration coordinated by United Way of Northeast Florida with several partners. FSS assists children whose grades are dropping, families in crisis and students who are having trouble controlling their emotions. The program is showing positive outcomes. Full Service Schools Plus is a pilot program that embeds a therapist in each of the 12 schools within the Ribault High School feeder pattern in northwest Jacksonville. Funded by a coalition of groups, it has already doubled the number of mental health referrals. By providing the resource in a school, it reduces barriers such as transportation and parental time. The model also provides a more timely response to the needs of children. Women in the Military and Women Veterans Military Sexual Trauma (MST), defined as rape, sexual assault and sexual harassment, affects both men and women and often leads to debilitating conditions such as Post Traumatic Stress Disorder (PTSD) and major depression. Historically, data about the extent of sexual assault has likely not captured the extent of the problem. However, a 2014 study and report by the Rand Corp. found the following for a one-year reporting timeframe: •
5 percent of active-duty women experienced sexual assaults.
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22 percent of active-duty women experienced sexual harassment.
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52 percent of those who reported harassment perceived professional or social retaliation after reporting.
Additionally, other reports suggest that women veterans commit suicide at seven times the rate of non-veteran women. MST is associated with a range of health and economic consequences for women in the military and women veterans: •
It is the primary cause of PTSD.
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It is a risk factor for homelessness, with 40 percent of homeless women veterans reporting experiences of sexual assault while in the military.
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The stress, depression and other mental health issues that accompany MST make it likely that survivors will experience high rates of substance abuse and have difficulty finding work after discharge from the military.
Women veterans are the fastest growing segment of those using the Veterans Administration. While efforts have increased to tailor services to better meet the needs of women veterans, a sample of women veterans using VA primary care services revealed: •
Of those who perceived a need for mental health assistance, 84 percent received care; however only half reported that their mental health care met their needs completely or very well.
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Greater availability of female providers, women-only treatment settings and women-only treatment groups is needed.
Locally, a WGA-funded research study on the needs of area women veterans, particularly health and mental health related needs, is underway under the auspices of the Northeast Florida Women Veterans Association. It is expected to provide assessment of local resources and future needs.
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Girls and Young Women Two organizations in Northeast Florida have undertaken important work to address the underlying mental health needs of girls and support them in their progress in school. Both organizations have received Women’s Giving Alliance grants to support this work. PACE has developed a research-based, non-residential program for middle and high school aged girls and young women. It features a balanced emphasis on academics and social services with a focus on the future. It has been recognized nationally as one of the most effective programs for keeping girls from entering the juvenile justice system. The approach is holistic and strength-based, with a focus on building assets. It includes both therapeutic counseling services at PACE, as well as connecting students with appropriate local services. The Delores Barr Weaver Policy Center’s “Girl Matters: It’s Elementary” curriculum serves girls who have experienced trauma. Implemented in some local elementary schools, it shifts the focus from punishment and dropping out of school to understanding the whole girl in the context of her life and needs. The center also has done extensive work regarding justice-involved girls. The report on its recent research and work is outlined in the Safety and Justice section of this report.
Stigma Remains a Concern People with mental health problems say that the social stigma attached to mental illness can make recovery more difficult. Among the continuing national and local mental health efforts are those to reduce the stigma associated with mental illness. National examples: •
“Bring Change 2 Mind,” a non-profit organization, conducts public educational media campaigns, distributes education materials and provides programs to end stigma. Its work has had significant exposure due to actress Glenn Close and her family’s commitment and involvement in its work.
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The National Alliance on Mental Illness’s education and involvement effort is called “stigmafree.”
Local examples: •
The JCCI Mental Health Report Implementation team is assessing the prospect of launching websites devoted to changing the perceptions associated with a mental illness.
Priorities for Change: Legislative and Policy Priorities Legislative changes in all levels of government are critical to developing effective solutions for mental health needs. The JCCI Mental Health Report resulted in funding from the Jessie Ball DuPont Fund to support collaboration between Mental Health America of Northeast Florida and The Children’s Campaign for a state-wide advocacy campaign. More than 200 people attended a summit to craft priorities for Florida’s 2016 legislative session. The priorities are outlined
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on MHA’s website and include increased funding for outpatient mental health services, Medicaid expansion and improvements to the Baker and Marchman Acts. For the accompanying portion of this report, see Voices of Hope Physical Health.
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