[Federal Register Volume 62, Number 60 (Friday, March 28, 1997)]
[Notices]
[Pages 14928-14932]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-7734]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Estimation Methodology for Adults with Serious Mental Illness
(SMI)
AGENCY: Center for Mental Health Services, Substance Abuse and Mental
Health Services Administration, HHS.
ACTION: Solicitation of comments.
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SUMMARY: This notice describes the proposed methodology for identifying
and estimating the number of adults with serious mental illness (SMI)
within each State. This notice is being served as part of the
requirement of Public Law 102-321, the ADAMHA Reorganization Act of
1992.
COMMENT PERIOD: The Administrator is requesting written comments which
must be received on or before May 27, 1997.
ADDRESSES: Comments should be sent to Ronald W. Manderscheid, Ph.D.,
Chief, Survey and Analysis Branch, Center for Mental Health Services,
Parklawn Building Room 15C-04, 5600 Fishers Lane, Rockville, MD 20857.
(301) 443-7926 fax.
FOR FURTHER INFORMATION CONTACT: A detailed paper outlining the
estimation methodology described here is available from Ronald W.
Manderscheid, Ph.D., Chief, Survey and Analysis Branch, Center for
Mental Health Services, Parklawn Building Room 15C-04, 5600 Fishers
Lane, Rockville, MD 20857. (301) 443-3343 voice, (301) 443-7926 fax.
Background
Public Law 102-321, the ADAMHA Reorganization Act of 1992, amended
the Public Health Service Act and created the Substance Abuse and
Mental Health Services Administration (SAMHSA). The Center for Mental
Health Services (CMHS) was established within SAMHSA to coordinate
Federal efforts in the prevention, treatment, and promotion of mental
health. Title II of Public Law 102-321 establishes a Block Grant for
Community Mental Health Services administered by CMHS, which permits
the allocation of funds to States for the provision of community mental
health services to children with a serious emotional disturbance and
adults with a serious mental illness. Public Law 102-321 stipulates
that States estimate the incidence (number of new cases) and prevalence
(total number of cases in a year) in their applications for Block Grant
funds. As part of the process of implementing this new block grant,
definitions of the terms ``children with a serious emotional
disturbance'' and ``adults with a serious mental illness'' were
announced on May 20, 1993, in Federal Register Volume 58, No. 96, p.
29422. Subsequently, a group of technical experts was convened by CMHS
to develop an estimation methodology to ``operationalize the key
concepts'' in the definition of adults with serious mental illness. A
similar group is preparing an estimation methodology for children and
adolescents with a serious emotional disturbance.
Data Sources
Data from two major national studies, the National Comorbidity
Survey (NCS) and the Epidemiologic Catchment Area (ECA) Study, were
used to estimate the prevalence of adults with serious mental illness.
The NCS, a nationally representative sample household survey conducted
in 1990-91 assessed the prevalence of DSM-III-R disorders in persons
aged 15-54 years old. This sample included over 1,000 census tracts in
174 counties in 34 States. The ECA, a general population survey of five
local areas in the U.S., was conducted in 1980-85 to determine the
prevalence of DSM III disorders in persons age 18 and older. The ECA
data utilized for the present analysis was limited to the Baltimore
site because that was the only site that had disability data needed to
operationalize the criteria for SMI. Although the Baltimore sample is
not nationally representative, it is used in this analysis because the
ECA provides a rough replication and check on the NCS data. Also, the
NCS does not have data on persons age 55 and older, so the ECA data are
used to estimate the prevalence of serious mental illness among persons
55 years and older. The group of technical experts determined that it
is not possible to develop estimates of incidence using currently
available data. However, it is important to note that incidence is
always a subset of prevalence. In future, incidence and prevalence data
will be collected.
Serious Mental Illness (SMI)
As previously defined by CMHS, adults with a serious mental illness
are persons 18 years and older who, at any time during a given year,
had a diagnosable mental, behavioral, or emotional disorder that met
the criteria of DSM-III-R AND ``* * * that has resulted in functional
impairment which substantially interferes with or limits one or more
major life activities * * *.'' The definition states that ``* * *
adults who would have met functional impairment criteria during the
referenced year without the benefit of treatment or other support
services are considered to have serious mental illnesses * * *.'' DSM-
III-R ``V'' codes, substance use disorders, and developmental disorders
are excluded from this definition.
The following criteria were used to operationalize the definition
of serious mental illness in the NCS and ECA data:
(1) Persons who met criteria for disorders defined as severe and
persistent mental illnesses (SPMI) by the National Institute of Mental
Health (NIMH) National Advisory Mental Health Council (National
Advisory Mental Health Council, 1993).
To this group were added:
(2) Persons who had another 12-month DSM-III-R mental disorder
(with the exclusions noted above), AND
Either planned or attempted suicide at some time during
the past 12 months, OR
Lacked any legitimate productive role, OR
Had a serious role impairment in their main productive
roles, for example, consistently missing at least one full day of work
per month as a direct result of their mental health, OR
Had serious interpersonal impairment as a result of being
totally socially isolated, lacking intimacy in social relationships,
showing inability to confide in others, and lacking social support.
[[Page 14929]]
Estimation Procedures
Two logistic regression models were developed to calculate
prevalence estimates for adults with SMI.
(a) A Census Tract Model for years in which the decennial U.S.
census is conducted.
(b) A County-Level Model to be used biannually in intercensal
years.
In non-censal years, the county-level model will be used to
estimate SMI prevalence, after adjusting for its known relationship
with the census tract model.
Formula
Census-Tract Model
Using 1990 census data, a logistic regression model was developed
to calculate predicted rates for each cell of an age by sex by race
table for each of the 61,253 Census Tracts in the country. Next, the
rates were multiplied by cell frequencies and subtotaled to derive
tract-level estimates. Finally, the tract-level estimates were
aggregated to arrive at county-level and state-level prevalence
estimates of adults with SMI. This regression methodology is often used
in small area estimation (Ericksen, 1974; Purcell & Kish, 1979). The
actual census tract model equation is specified immediately below:
Parameter Estimates for Census-Tract Model
------------------------------------------------------------------------
95% confidence
Predictor Odds ratio interval
------------------------------------------------------------------------
Intercept............................... *0.02 (0.01-0.04)
------------------------------------------------------------------------
Individual-Level Variables
------------------------------------------------------------------------
Age:
18-24............................... *1.94 (1.18-3.17)
25-34............................... 1.32 (0.86-2.03)
35-44............................... 1.46 (0.96-2.21)
45-54............................... 1.00 (--)
Sex:
Female.............................. *2.23 (1.57-3.19)
Male................................ 1.00 (--)
Race:
Nonhispanic white................... 1.00 (--)
Black/Hispanic/other................ *0.49 (0.28-0.87)
Marital Status:
Married/Cohabiting.................. 1.00 (--)
Never Married....................... *3.90 (1.15-3.08)
Separated/Divorced/Widowed.......... *1.88 (2.41-6.31)
------------------------------------------------------------------------
Census-Tract Level Variables
------------------------------------------------------------------------
F2 (High socio-economic status)......... 1.16 (0.90-1.49)
F4 (Immigrants)......................... 0.99 (0.85-1.14)
------------------------------------------------------------------------
County-Level Variables
------------------------------------------------------------------------
County Urbanicity:
Metropolitan........................ 1.12 (0.85-1.49)
Other............................... 1.00 (--)
------------------------------------------------------------------------
Interactions Among Variables
------------------------------------------------------------------------
FemaleXSeparated/Divorced/Widowed....... *0.47 (0.24-0.91)
FemaleXNever Married.................... *0.47 (0.28-0.78)
Non WhiteXSeparated/Divorced/Widowed.... *2.62 (1.29-5.33)
Non WhiteXNever Married................. 1.81 (0.95-3.44)
FemaleXF2............................... *0.70 (0.51-0.96)
UrbanicityXF2........................... *0.75 (0.52-0.95)
F2XF4................................... 0.78 (0.64-0.94)
------------------------------------------------------------------------
* Significant at the .05 level, two tailed test; F2=Census Tract factor
score for high socioeconomic status (SES); F4=Census Tract factor
score for immigrants.
The estimate for persons 55 years and older is derived from
analysis of ECA data in conjunction with NCS data. The prevalence ratio
among ECA respondents ages 55-64 and 65 years and above, were found to
be 84 and 31 percent as large, respectively, as the prevalence estimate
for NCS respondents 18-54 years old, after controlling for differences
in gender and race. NCS State-level estimates were extrapolated using
these ratios. These ratios did not differ significantly by sex or race.
A factor of .81 was applied to State-level SMI estimates for the age
range 18-54 to derive the rate for the age range 55-64, and .31 was
used to arrive at the estimate for person 65 and older. A weighted sum
(by age distribution of each State) was calculated to determine the
final State-level SMI prevalence estimate.
County Model
U.S. Census Bureau tract-level data are available only for years in
which the decennial U.S. Census is conducted. To obtain prevalence
estimates for adults with a SMI during intercensal years, the group of
technical experts used biennial individual- and county-level data from
the Census Bureau's small area estimation program. Predicted values
[[Page 14930]]
from the logistic regression equation were used to calculate county-
level estimates. In contrast to the census tract model, the initial
estimates using this approach were generated at the county level. These
county-level estimates are then summed to provide State-level
prevalence estimates. The actual county-level model equation is
specified immediately below:
Parameter Estimates for County-Level Model
------------------------------------------------------------------------
95% confidence
Predictor Odds ratio interval
------------------------------------------------------------------------
Intercept............................... *0.04 (0.02-0.07)
------------------------------------------------------------------------
Individual-Level Variables
------------------------------------------------------------------------
Age:
18-24............................... 1.69 (1.00-2.85)
25-34............................... 1.10 (0.65-1.88)
35-44............................... 1.24 (0.71-2.15)
45-54............................... 1.00 ( - )
Sex:
Female.............................. 1.58 (1.17-2.13)
Male................................ 1.00 ( - )
------------------------------------------------------------------------
County-Level Variables
------------------------------------------------------------------------
Urbanicity:
Metropolitan........................ 1.35 (0.99-1.85)
Other............................... 1.00 ( - )
------------------------------------------------------------------------
* Significant at the 0.05 level, two-tailed test.
Adjustment for persons age 55 years and older is carried out as in
the census-tract model. An adjustment factor (Census Bureau, Fay, 1987;
Fay & Herriot, 1979) based on the ratio of county-level model estimates
for 1990 and census-tract model estimates for 1990 can be used to
adjust biannual estimates for subsequent years from the county-level
model. This procedure assumes that the census-tract model is more
accurate than the county-level model.
County and State Estimates
As stated earlier, census tract model prevalence estimates were
summed to derive county estimates, and county estimates were summed to
arrive at State estimates. The 12-month prevalence is estimated
nationally to be 5.4 percent or 10.0 million people in the adult
household population, of which 2.6 percent or 4.8 million adults have a
serious and persistent mental illness (figure 1).
The above estimates are based on noninstitutionalized persons
residing in the community. Limited information currently exists on SMI
estimates for persons institutionalized (i.e., persons in correctional
institutions, nursing homes, the homeless, persons in military
barracks, hospitals/schools/homes for persons who are mentally ill or
mentally retarded). Fischer and Breakey (1991), indicate that on
average, the SMI prevalence rate for these groups (including about 5
million people or 2.7 percent of the U.S. adult population) is about 50
percent. The following assumptions were made in deriving rough
estimates of SMI prevalence for persons who are institutionalized:
(a) For 1.1 million residents of correctional institutions, 100
percent of whom are adults, prevalence of SMI is estimated to be 57
percent.
(b) For 1.8 million residents of nursing homes, 100 percent of whom
are adults, prevalence of SMI is estimated to be 46 percent.
(c) For 0.5 million persons who are homeless, 80 percent of whom
are adults, prevalence of SMI is estimated to be 50 percent.
(d) For 0.6 million persons in military barracks, all of whom are
adults, the SMI prevalence rate is equivalent to that of the adult
household population.
(e) For 0.4 million persons in hospitals, homes, and schools for
persons who are mentally ill, 80 percent of whom are adults, prevalence
of SMI is estimated to be 100 percent.
(f) For 0.6 million persons in other institutional settings such as
chronic disease hospitals, homes and schools for persons with physical
disability, and rooming houses, 50 percent of whom are adults,
prevalence of SMI is estimated to be 50 percent.
State estimates of each of these populations can be added to the
State SMI populations identified below.
Only a portion of adults with SMI seek treatment in any given year.
Due to the episodic nature of SMI, some persons may not require mental
health service at any particular time.
Provision of Estimates to States
CMHS will provide each State mental health agency with estimates in
order to initiate the first cycle of use. Subsequently, CMHS will
provide technical assistance to States to implement the methodology
using State demographic information.
Table 1.--Estimated 12-Month Prevalence of Serious Mental Illness (SMI) Among Persons Ages 18 and Older, by
State, 1990*+
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Number of people Total adult
State with SMI population 18 yrs+ Prevalence of SMI
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Alabama............................................. 172,944 2,981,799 5.8
Alaska.............................................. 23,795 377,699 6.3
Arizona............................................. 179,835 2,684,109 6.7
[[Page 14931]]
Arkansas............................................ 95,128 1,729,594 5.5
California.......................................... 1,386,586 22,009,296 6.3
Colorado............................................ 160,586 2,433,128 6.6
Connecticut......................................... 129,414 2,537,535 5.1
Delaware............................................ 28,661 502,827 5.7
District of Columbia................................ 28,409 489,808 5.8
Florida............................................. 624,445 10,071,689 6.2
Georgia............................................. 299,308 4,750,913 6.3
Hawaii.............................................. 31,468 828,103 3.8
Idaho............................................... 38,409 698,344 5.5
Illinois............................................ 500,570 8,484,236 5.9
Indiana............................................. 237,115 4,088,195 5.8
Iowa................................................ 109,067 2,057,875 5.3
Kansas.............................................. 103,510 1,815,960 5.7
Kentucky............................................ 161,141 2,731,202 5.9
Louisiana........................................... 176,570 2,992,704 5.9
Maine............................................... 48,703 918,926 5.3
Maryland............................................ 220,773 3,619,227 6.1
Massachusetts....................................... 265,811 4,663,350 5.7
Michigan............................................ 410,192 6,836,532 6.0
Minnesota........................................... 179,666 3,208,316 5.6
Mississippi......................................... 100,455 1,826,455 5.5
Missouri............................................ 216,728 3,802,247 5.7
Montana............................................. 30,002 576,961 5.2
Nebraska............................................ 62,066 1,149,373 5.4
Nevada.............................................. 65,152 904,885 7.2
New Hampshire....................................... 49,830 830,497 6.0
New Jersey.......................................... 314,328 5,930,726 5.3
New Mexico.......................................... 69,441 1,068,328 6.5
New York............................................ 768,930 13,730,906 5.6
North Carolina...................................... 296,326 5,022,488 5.9
North Dakota........................................ 23,634 463,415 5.1
Ohio................................................ 474,795 8,047,371 5.9
Oklahoma............................................ 133,898 2,308,578 5.8
Oregon.............................................. 124,973 2,118,191 5.9
Pennsylvania........................................ 508,863 9,086,833 5.6
Rhode Island........................................ 48,222 777,774 6.2
South Carolina...................................... 156,556 2,566,496 6.1
South Dakota........................................ 24,877 497,542 5.0
Tennessee........................................... 230,617 3,660,581 6.3
Texas............................................... 850,547 12,150,671 7.0
Utah................................................ 71,201 1,095,406 6.5
Vermont............................................. 24,341 419,675 5.8
Virginia............................................ 280,957 4,682,620 6.0
Washington.......................................... 216,318 3,605,305 6.0
West Virginia....................................... 70,195 1,349,900 5.2
Wisconsin........................................... 205,359 3,602,787 5.7
Wyoming............................................. 17,812 318,063 5.6
-----------------------------------------------------------
*Total........................................ 9,995,579 185,103,320 5.4
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Does not include persons who are homeless or are institutionalized.
+ The total for the U.S. is based upon direct, weighted counts from the survey results. The total for each State
is based upon synthetic modeling at the county level and then summing across counties to derive a State total.
These two approaches are subject to different types of sampling and nonsampling errors. Therefore, the sum of
the state totals will not necessarily equal the U.S. total.
Limitations
The ECA and NCS were designed to study lifetime prevalence of
mental disorders rather than 12-month prevalence. As a result, the
emphasis in diagnostic assessment was on lifetime disorders. In
addition, functional impairment was not a primary focus in either the
ECA or the NCS.
Current data cannot provide estimates of incidence. Additional
information needs to be collected in the future.
Scope of Application
Inclusion in or exclusion from the definition is not intended to
confer or deny eligibility for any service or benefit at the Federal,
State, or local levels. Additionally, the definition is not intended to
restrict the flexibility or responsibility of the State or local
government to tailor publicly funded service systems to meet local
needs and priorities. However, all individuals whose services are
funded through Federal Community Mental Health Services Block Grant
funds must fall within the criteria set forth in these definitions. Any
ancillary use of these definitions for purposes other than those
identified in the legislation is outside the purview and control of
CMHS.
[[Page 14932]]
It is anticipated that additional work will be done in future years
to refine and update the estimation methodology. CMHS will keep States
apprised as this work develops.
References
Ericksen, E. P. (1974). A regression method for estimating
population changes of local areas. Journal of American Statistical
Association, 69, 867-875.
Fay, R. E. (1987). Application of multivariate regression to small
domain estimation. In R. Platek, J.N.K. Rao, C.E. Sarndal & M.P.
Singh (Eds.), Small Area Statistics: An International Symposium, Pp.
91-102. New York: John Wiley and Sons.
Fay, R. E., & Herriot, R. A. (1979). Estimates of income for small
places: An application of James-Stein procedures to Census data.
Journal of the American Statistical Association, 74, 269-277.
Fischer, P.J., Breakey, W.R. (1991). The Epidemiology of alcohol,
drug, and mental disorders among homeless persons. American
Psychologist. 46, 1115-1125.
Kessler, R.C., et al. Estimation of the 12-month Prevalence of
Serious Mental Illness (SMI). (1996). Unpublished document.
National Advisory Mental Health Council. (1993). Health care reform
for Americans with severe mental illness. American Journal of
Psychiatry, 150, 1447-1465.
Purcell, N. J., & Kish, L. (1979). Estimation for small domains.
Biometrics, 35, 365-384.
Regier, D. A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Locke,
D.Z., Goodwin, F.K. (1993). The de Facto US Mental and Addictive
Disorders Service System. Archives of General Psychiatry, 50, 85-94.
Dated: March 5, 1997.
Richard Kopanda,
Executive Officer, Substance Abuse and Mental Health Services
Administration.
BILLING CODE 4162-20-P
[GRAPHIC] [TIFF OMITTED] TN28MR97.014
[FR Doc. 97-7734 Filed 3-27-97; 8:45 am]
BILLING CODE 4162-20-C