Priority: Improve Mental Health
Objective for SPM 21: Decrease the percent of women who reported 14+ days of poor mental health in the past month from 17.8% in October 1, 2021 to 17% in September 30, 2025.
Objective for SPM 22: Increase the percent of children, ages 3 through 17, with a mental/behavioral condition who receive treatment or counseling. from 46.6% on October 1, 2022, to 55% on September 30, 2025.
Description: Tennessee is facing a pediatric mental health crisis. According to data from the TN Youth Risk Behavior Survey[1] (YRBS), the percentage of students who reported feeling sad and hopeless increased from 31.1% in 2017 to 37.5% in 2019. Gender disparities exist; among those who reported feeling sad or hopeless, 47.1% were female and 27.9% were male. The percentage of high school students who seriously considered attempting suicide also increased from 16.5% in 2017 to 19.2% in 2019 and was more commonly reported among females. The percentage of high school students who made a plan about how they would attempt suicide also increased during this time, from 13% in 2017 to 15.5% in 2019. Finally, there was an increase in the percentage of high school students who attempted suicide and in the percentage of high school students who had a suicide attempt that resulted in an injury, poisoning or overdose that had to be treated by a doctor or nurse (from 8.3% to 10.6% and 2.9% to 3.9%, respectively). Gender disparities continue to be observed among those who attempted suicide. Racial/ethnic disparities are also present. Among those who made a plan about how they would attempt suicide, 18.9% were Hispanic, 15.6% were non-Hispanic White and 13% were non-Hispanic Black. Among those who attempted suicide, 15.8% were Hispanic, 14% were non-Hispanic Black and 9.1% were non-Hispanic White. In addition, among those who had a suicide attempt that resulted in an injury, poisoning or overdose that had to be treated by a doctor or nurse, 7.5% were non-Hispanic Black, 6.4% were Hispanic and 2.7% were non-Hispanic White.
Suicide continues to be a growing public health problem in Tennessee. Over the past five years, Tennessee’s suicide death rate has remained higher than the average national rate[2]. In 2018, Tennessee’s suicide rate (17.1 deaths per 100,000 person population) was 16% higher than the national average rate (14.8 deaths per 100,000 person population). Suicide has increased among individuals 10 -24-year-olds over the last five years (from 8.9 deaths per 100,000 to 10.7 deaths per 100,000). Furthermore, youths between the ages of 15 and 24 experienced the highest rates for both nonfatal intentional self-harm injury and suicidal ideation (397 per 100,000 and 852.3 per 100,000, respectively) out of all the age groups, according to 2016-2018 hospital discharge data[3].
TDH conducts weekly surveillance of suicide-related emergency department visits in children aged 18 and under[4]. The visits are monitored using the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) software, a data feed that includes emergency department visits for a suicide attempt, intentional self-harm, or thoughts of suicide. When the number of emergency room visits for suicide-related behaviors goes above a certain threshold for a particular region, an alert is generated, which allows for a rapid response at the local level. Interventions include increasing awareness and offering suicide prevention resources, services, and programs within a county seeing increases in near real time. In 2020, there were 6,156 youth suicide-related ED visits and 305 alerts across Tennessee. From January 1, 2021 to June 14, 2021, there were 4,722 suicide-related ED visits and 172 alerts, a significant increase. Of note, 150 of these visits were among children between the ages of 6-9. Gender disparities continue to persist; more than two times the number of suicide-related ED visits were among females. Primary diagnoses and other risk factors noted during these ED visits included: Major Depressive Disorder, hallucinations, poor physical condition/neglect, psychiatric issues, bullying, loss of family or friend, lack of family support, identification with LGBTQ+, distress associated with relocation, and COVID-19 isolation. The specific suicidal behavior noted during these ED visits included: overdose with non-prescription drugs (e.g., pain relievers and sleeping medication), overdose with prescription drugs (e.g., opioid pain medication such as oxycodone), arm/neck lacerations, jumping into traffic, hanging/suffocation, cutting/mutilation, and self-isolation.
[1] Centers for Disease Control and Prevention. Tennessee Youth Risk Behavior Surveillance System. Available at https://nccd.cdc.gov/Youthonline/App/
[2] Tennessee Department of Health, Office of Vital Records and Statistics, Death Statistical File, 2014-2018.
[3] Tennessee Department of Health, Division of Population Health Assessment, Hospital Discharge Data System.
[4] TN Department of Health, Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE).
Disparity Elimination Focus: The team will focus on the place-based disparity, specifically disparities in Shelby County, Tennessee. According to the 2021 Robert Wood Johnson County Health Rankings, 26% of children in Shelby County live in poverty, which is higher than the Tennessee average (19%)[1]. In Shelby County, 58% of the under 18 population is Black and 35% is White. According to data from the 2019 American Community Survey, among individuals 18 years old and younger, 43% had public insurance or a combination of public and non-public insurance[2]. As in many counties in Tennessee, there is a shortage of mental health providers. The ratio of population to mental health providers is 670:1 (range in Tennessee is 16,830:1 to 270:1). Shelby County’s High School YRBS results also highlight an increase in feelings of sadness or hopelessness (from 29.7% in 2017 to 36.2% in 2019). Similarly, the percentage of high school students who seriously considered attempting suicide increased and was slightly higher than the statewide percentage (18.6% in 2017 to 20.7% in 2019). The percentage of high school students who made a plan about how they would attempt suicide also increased during this time period and was higher than the statewide percentage (14.8% in 2017 to 16.6% in 2019). Children in Shelby County, in particular children of color, face barriers in access to behavioral health care due to racial/ethnic inequities. There is an insufficient number of behavioral health clinicians to meet the needs of children in Shelby County, and a behavioral health tele-consultation service is not currently offered in this underserved area. The place-based disparity will be addressed through Strategy 3 below.
[1] Robert Wood Johnson County Health Rankings 2021. Available at https://www.countyhealthrankings.org/app/tennessee/2021/rankings/shelby/county/outcomes/overall/snapshot.
[2] U.S. Census Bureau, 2019 American Community Survey 1-Year Estimates.
The following strategies and activities are planned for October 1, 2023, to September 30, 2024:
Strategy 1: Use evidence-based screening tools to screen pregnant and postpartum women for perinatal mood and anxiety disorders and refer to mental health resources, if indicated.
Supporting Evidence for Strategy 1: 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).
Activity 1b: Connect women with mental health needs identified through screening to resources
Strategy 2: Support Le Bonheur Children’s Hospital Emergency Department’s (ED) implementation of universal suicide risk screening in the ED
Supporting Evidence for Strategy 2: The 2022 American Academy of Pediatrics/Bright Futures Recommendations for Preventive Pediatric Care recommends screening for suicide risk for all youth ages 12 and above. For youth ages 8-11, it is recommended to screen when clinically indicated.
Activity 2a: Train ED staff on suicide risk assessment.
Activity 2c: Improve the follow-up of children with mental health concerns after ED discharge.
Strategy 3: Launch the Pediatric Mental Health Care Access Program in West TN
Activity 3a: Establish a regional pediatric mental health team, to include onboarding of new staff, establishing an Advisory Committee with diverse representation, and supporting youth and family engagement through on-going feedback.
Activity 3b: Pilot a phone-based consultation service with PCPs in Shelby County. As part of the pilot, the team plans to focus efforts on the most socio-demographically vulnerable populations.
Activity 3c: Offer training on the early identification and management of children with behavioral health conditions to PCPs in West TN. The training is evidence-based and will cover the principals of providing trauma-informed care that is culturally and linguistically appropriate and family-centered in an effort to address behavioral health inequities.
Planned Partnerships: TN Department of Mental Health and Substance Abuse Services (TNDMHSAS); University of Tennessee Le Bonheur Pediatric Specialists (ULPS); Le Bonheur Children’s Hospital Emergency Department; TDH Health Disparities Task Force, Tennessee Commission on Children and Youth (TCCY); Young Child Wellness Council (YCWC); Regional and Metro Health Departments; TN Chapter of the American Academy of Pediatrics (TNAAP); Pediatric Providers, Mental Health Providers, and Hospitals; Families and Youth Self-Advocates; Schools;
Contextual Factors:
- Patient/client barriers in access to programs, primary care, and behavioral healthcare
- Readiness of collaborative partners
- Financial resources
Assumptions:
- Women and families will enroll in EBHV and CHANT
- Healthcare providers, teachers, and counselors will participate
- Stakeholders will be engaged
- Families and youth will be open to support
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