Priority:  Improve Mental Health

MCH/Title V Funding: The Mental Health priority team is administratively led by the Associate Medical Director of Pediatrics within the Division of Family Health and Wellness of TDH. The Associate Medical Director provides leadership for the Neonatal Abstinence Syndrome (NAS) Surveillance, Pediatric Mental Health, and School Health programs and provides pediatric consultation to programs across TDH and other state agencies. The mental health improvement efforts are supported by federal funds. While MCH/Title V does not directly fund the activities highlighted in the annual report, it does fully fund some staff who support mental health improvement efforts, including the Deputy Medical Director and Associate Medical Director who provides leadership for this area.

Interpretation of Performance Data on selected NPMs, SPMs, and SOMs:

SPM 21: Percent of women who reported 14+ days of poor mental health in the past month

The percent of women who reported 14 or more days of poor mental health in the past month, based on Behavioral Risk Factor Surveillance System (BRFSS) 2021 data, was 21.3%. This is the first year that this measure has been tracked as part of the mental health priority area, but it is an increase from 2020 (17.8%)

Women’s mental health has been greatly affected by the COVID-19 pandemic. Gender disparities in mental health and in socioeconomic factors that affect mental health existed pre-pandemic and have been further exacerbated by COVID. Furthermore, the current mental health resources are insufficient to meet the mental health needs. A Kaiser Family Foundation poll[1] underscored the challenges that many women have faced since women are more likely to be the primary caretakers and lead health care responsibilities for the family. According to the poll, more women that men worried that they or someone in their family would get sick from COVID and worried about losing income. More women also reported feeling the negative mental health effects from worrying about COVID.

SPM 22: Percent of children who had difficulties obtaining mental health care among those who received or needed care during the past 12 months, age 3-17 years

State-level data is unavailable for this measure, and nationwide data for this measure was last available in 2020. An alternative measure from the National Survey of Children’s Health (NSCH) is the percent of children, ages 3 through 17, with a mental/behavioral condition who receive treatment or counseling. This measure improved, from 46.6% (combined 2019-2020 data) to 49.3% (combined 2020-2021 data). The improvement in access to mental health treatment or counseling could be due to expansion of telemedicine and insurance coverage for telemedicine services since the pandemic, the integration of behavioral health care into pediatric primary care, and expansion of school-based mental health support and services.

SOM 8: Percent of pregnancy-associated deaths in which mental health conditions was a contributing factor

Based on 2017-2020 Maternal Mortality Review (MMR) data, mental health contributed to 23% of pregnancy-associated deaths. This is the first year that this measure has been tracked as part of the mental health priority area, but it is an increase from 2017-2018 MMR data (21%).

There are many factors contributing to the worsening of this measure. Among the 23% of pregnancy-associated deaths in which a mental health condition was a contributing factor, substance use disorder was also a contributing factor. In addition to the impacts of COVID on mental health, researchers have observed increases in substance use and drug overdoses in the US during the pandemic. Perinatal mental health is also impacted by stigma, barriers in access to mental health and substance use disorder treatment, inadequate screening for mental health conditions during the perinatal period, lack of care coordination, and inadequate prenatal care.

Accomplishments and Challenges (based on FY2022 Action Plan):

Strategy 1:  Ensure that postpartum women receive a mental health screening and are referred to appropriate resources.

Supporting Evidence for Strategy: The US Preventive Services Task Force (USPSTF), American College of Obstetricians and Gynecologists (ACOG), and other women’s health organizations recommend that pregnant and postpartum women be assessed for risk of depression so that they can receive intervention before symptoms arise.

Activity 1a: Conduct mental health screenings among women enrolled in Community Health Access and Navigation in TN (CHANT) and Evidence Based Home Visiting (EBHV).

Report 1a: As part of the CHANT comprehensive screening and assessment, each member of the family unit is screened for mental/behavioral health needs. In addition, all postpartum women are screened for depression using the Edinburgh Postnatal Depression Scale (EPDS). Positive screens trigger the Pregnancy/Postpartum Pathway of Care, and an action step on this pathway is to provide perinatal depression education.

EBHV is a relationship-based program that is culturally competent, strengths-based, and family-centered. The EBHV models are equipped to work with families who may have experienced trauma, intimate partner violence, poor mental health, or substance abuse diagnoses. As part of the EBHV services, home visitors screen for maternal depression using the EPDS.

Activity 1b: Connect women with mental health needs identified through screening to resources

Report 1b: Among EBHV participants, 100% of primary caregivers with positive screens for perinatal depression were referred to mental health services or resources (ESM 1.9). This is the first year that this measure has been tracked as part of the mental health priority area.

 Within the CHANT program, 33.4% of postpartum women with positive screens received resources. This is the first year that this measure has been tracked as part of the mental health priority area.

 The differences in the percent of women with positive screens who were connected to resources can be explained by differences between the EBHV and CHANT programs and when the EPDS is administered. For the EBHV programs, the EPDS is administered when the caregiver is already enrolled in the program and receiving services. EBHV services are relationship-based and designed to improve long-term outcomes for families. The focus on building a trusted relationship between the home visitor and caregiver could have led to the high percent of women identified with mental health needs who are referred to services.

The CHANT program has the capacity to screen more women for perinatal depression. For example, in FY2022 344 postpartum women had positive perinatal depression screens in comparison to 60 in the EBHV program. A positive screen automatically triggers the Pregnancy/Postpartum Pathway of Care. However, participants can decline services or pathways of care at any point. Among those who had positive screens and accepted being placed on the Pregnancy/Postpartum Pathway, 115 (33.4%) received postpartum depression education. It’s important to note that, because CHANT has a broader reach, more women with positive screens were connected to resources in comparison to the EBHV program.

Challenges Issues Related to Implementation of Strategy 1: The primary challenge related to implementing this strategy in the EBHV program is the smaller number of women who are screened in comparison to the CHANT program. CHANT has a broader reach; however, caregivers have not enrolled in services or established a relationship with a care coordinator at the time that they are screened. Caregivers may decline services between the time that they are identified and provided resources.

Strategy 2:  Provide QPR training opportunities to equip individuals with skills to recognize and respond to individuals exhibiting suicidal warning signs and promote the utilization of the TN Park Prescription Program to improve physical and mental health.

Supporting Evidence for Strategy: Evidence suggests that school-based gatekeeper training is effective in improving participants’ knowledge, skills, self-efficacy and likelihood to intervene. Question, Persuade, Refer (QPR) Gatekeeper Training is designed to teach participants how to recognize the warning signs of someone who may be contemplating suicide and question them about whether or not they are suicidal; how to offer hope to an individual experiencing a suicidal crisis and persuade them to get help; and how to refer an individual having a suicidal crisis for help in order to save their life.

Healthy Parks Healthy Person TN’s Park Prescription Program promotes spending time outdoors to improve physical and mental health.

Activity 2a: Support Question, Persuade, Refer (QPR) Gatekeeper Training for teachers and other school personnel

Report 2a: A total of 38 Question, Persuade, Refer (QPR) suicide prevention trainings were delivered to 1,455 individuals via Tennessee Suicide Prevention Network partner staff and trained volunteers. Of the 1,455 who received training, 789 were teachers or school personnel.

The most significant challenge to implementing this strategy was the high amount of turnover in the partner agency, the Tennessee Suicide Prevention Network (TSPN) who experienced significant staff turnover in FY 22.  Of the nine total employees, four left the agency.  Two of those were senior leaders who worked closely to coordinate TSPN staff and volunteers to train school personnel for QPR.  Also, schools continue to be judicious with staff training time since COVID-19.  Suicide training requirements can also be fulfilled with individual online teacher training provided by the Jason Foundation.  Finally, TSPN utilizes a number of volunteers to promote and deliver QPR training and volunteerism for TSPN activities decreased in some regions of the state.  TSPN is almost fully staffed now, and the Suicide Prevention Program intends to work closely with the new leadership team to ensure that QPR training goals for school officials are met in FY 23. 

Activity 2b: Promote mental health benefits of park prescription program in health department clinics

Report 2b: The mental and physical health benefits of the park prescription program continue to be promoted in local health department clinics. In FY2022, 57% of local health department clinics shared park prescriptions with patients. This measure exceeded the goal of 25%.

In October 2022, Healthy Parks Healthy Person, an app that rewards visitors to Tennessee parks for participating in outdoor activities, received national recognition. The app, which currently has over 11,000 users, allows participants to earn points that can be redeemed for rewards, such as backpacks. The program also includes a park prescription feature, allowing healthcare providers to prescribe an outdoor activity.

During the reporting period, the new app was promoted through the TDH website, promotion to internal and external partners, presentations to local Public Health Educators, and development of two PBS television spots. The Healthy Parks Healthy Person Program Director presented the prescription program and app during the Health Promotion Quarterly Call.  Participants included health promotion staff and public health educators from local, regional, state, and metro health departments.

Challenges Issues Related to Implementation of Strategy 2: The primary challenges with implementing QPR training include limited staff capacity at partner agencies, such as the Tennessee Suicide Prevention Network, and limited opportunities to train teachers and school personnel due to competing priorities and demands.

The main challenge with promoting the park prescription program is identifying ways to reach health department providers who also have competing demands and priorities.

Update on Other Related Programs Supported by MCH/Title V:

Suicide Prevention Program: TDH staff provided informational sessions to stakeholders to promote the Counseling for Access to Lethal Means (CALM) training to state partners and providers.  CALM is designed to help patients and families reduce access to lethal means, such as firearms and medication.  The program was successful in sharing information about CALM training via presentations to The Tennessee Trauma Care Advisory Council, Tennessee Commission on Children and Youth, and Committee on Pediatric Emergency Care, Maternal Child Health Task Force, Tennessee Department of Health (TDH) Mental Health Group and Tennessee Injury Prevention Coalition.  The program also supported injury prevention partners to develop and deliver 30 virtual trainings on best practices for utilizing telehealth to reduce suicide.  Fifteen topics were covered during one-hour sessions to non-licensed and licensed behavioral health providers throughout Tennessee.  Finally, the program delivered weekly ESSENCE suicide reports to partners throughout the state so they could monitor trends in suicidal behavior and risk factors in their counties and regions.  Available data included: Suicide Related ED Alerts for Children Under 18 and Adult Age Groups: 18-24, 25-44, 45-64, and 65+ and Age Groups, Race, Location, and Gender of Patients and Risk Factors for All Ages.

[1] https://www.kff.org/coronavirus-covid-19/issue-brief/coronavirus-a-look-at-gender-differences-in-awareness-and-actions/