Estimation Methodology for Adults with Serious Mental Illness (SMI)

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

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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]

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