[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
    <bullet> Either planned or attempted suicide at some time during 
the past 12 months, OR
    <bullet> Lacked any legitimate productive role, OR
    <bullet> 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
    <bullet> 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<SUP>*+                                                 
----------------------------------------------------------------------------------------------------------------
                                                       Number of people       Total adult                       
                        State                              with SMI       population 18 yrs+   Prevalence of SMI
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Does not include persons who are homeless or are institutionalized.                                             
<SUP>+ 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