Texas Statewide Behavioral Health Strategic Plan 4.1.3 Behavioral Health in Texas: Estimated Prevalence It is important to discuss mental health conditions in broad terms because the goals of this strategic plan affect the populations served by Council agencies as diverse as TVC, TEA, DFPS, and TDCJ. Council agencies serve populations with differing behavioral health needs and have differing eligibility requirements often determined by funding requirements or statute. Drawing a distinction between the different definitions of mental illness used by state agencies highlights the implications of accounting for overlap in each population, especially as it pertains to prevention and early intervention and the array of behavioral health services provided by Council agencies in Texas. Mental Health Disorders The federal Substance Abuse and Mental Health Services Administration (SAMHSA) defines serious mental illness (SMI) as a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment among people who are age 18 and older that substantially interferes with or limits one or more major life activities. Of the almost 27 million Texans, it is estimated that there are approximately 19.8 million adults age 18 years and older and 7.1 million children age 17 years old and younger. Based on a recent Texas study estimating prevalence at the county level9 and using SAMHSA's SMI algorithm10, it is estimated that close to 1 million adults, or 5 percent of the total Texas adult population, have SMI. A subset of people with SMI have serious and persistent mental illness (SPMI) which is inclusive of people with diagnoses such as schizophrenia, bipolar disorder, major depression, post-traumatic stress disorder, schizoaffective disorder, obsessive-compulsive disorder, anxiety disorder, attention deficit disorder, delusional disorder, and eating disorders. Those with SPMI experience significant functional impairment due to a mental health disorder that requires crisis resolution or ongoing, long-term support and treatment. Based on the SAMHSA methodology, an estimated 515,875 Texas adults lived with SPMI in fiscal year 2014. SAMHSA refers to severe mental health needs for children ages 17 years and younger as severe emotional disturbance (SED). These are diagnosable mental, behavioral, or emotional disorders in the past year, which resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in family, school, or community activities. Using SAMHSA's prevalence rate, the estimated number of Texas children and youth ages 17 years and younger with SED is 519, 368. 11 Texas schools use the term emotional disturbance when students are eligible for special education services based on the criteria that an emotional disturbance is determined to be the primary disability that adversely affects a child's educational performance in accordance with federal law outlined in 34 Code of Federal Regulations, §300.8(c)(4).12 The written evaluation 10 Page Texas Statewide Behavioral Health Strategic Plan report for students in schools must include specific recommendations for behavioral supports and interventions. Medical indigence is the primary indicator to determine financial eligibility for state behavioral health programs provided through DSHS. Section 552.012 of the Texas Health and Safety Code defines a medically indigent person as (1) one who does not own property; (2) is not under the care of someone who is legally responsible for the patient's support; and (3) does not have the ability to reimburse the state for the cost of the treatment and related costs.13 At the individual level, $23,540 annual income for a family of one, or $48,500 annual income for a family of four is considered 200 percent of the Federal Poverty Level (FPL). Individuals who meet these criteria are eligible for indigent care services from the state of Texas. 14 As an example, DSHS operationalizes medical indigence by requiring that a person or family be living at or below 150 percent FPL to receive full state funding for mental health treatment; whereas, if an individual needs SUD treatment, that person's or family's adjusted income must be at or below 200 percent FPL. If a person does not meet these criteria, a fee is assessed for services using a sliding scale.15 Based on data available from DSHS, it is estimated that roughly one-half of the populations with SMI, SPMI, and SED meet the criteria for medical indigence. 16 Substance Use Disorders According to SAMHSA, SUDs occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.17 SUD prevention and treatment programs are funded through a variety of Council agencies, including DSHS, HHSC, TDCJ, TJJD, the Health Professions Council, and the Office of the Governor. An estimated 1.6 million adult Texans, or nearly 6 percent of the total adult population, have SUD. Of those adults, approximately 42 percent (or 679,228) live at or below 200 percent FPL. An estimated 181,938 children age 12 to 17 years have SUD. Of those children, 57 percent (or 103,559) live at or below 200 percent FPL. One challenge to providing SUD prevention and treatment programs is the capacity of the current behavioral health system. Table 3 compares the estimated total number of individuals with SUD with the estimated numbers of individuals with SUD living at or below 200 percent FPL and those who actually accessed SUD treatment through DSHS programs and services. Of the potentially eligible population, only six percent of adults and five percent of children accessed services. 11 Page Texas Statewide Behavioral Health Strategic Plan Table 3: DSHS Estimated Need: SUD (Alcohol or Illicit Drug Dependency) for Children and Adults in Texas Compared to Numbers Served, Fiscal Year 2014 SUD Population Individuals Receiving Services through DSHS Eligible Individuals* Individuals in Need of Services Adults (Age 18 and Above) 41,002 Children (Age 12 to 17) 5,423 679,228 103,559 1,601,196 181,938 * Eligibility is based on income at or below 200 percent FPL. According to SAMHSA, 7.9 million adults in the United States had a co-occurring disorder in 2014.18 Co-occurring disorders describes the presence of two or more disorders at the same time. This includes the coexistence of mental illness and SUD, but may also include the coexistences of IDD and mental illness. SAMHSA indicates that there is a higher prevalence of co-occurring disorders among certain populations such as criminal justice, veterans, and homeless individuals.19 Chart 1: Estimated Prevalence for Texas Populations by Behavioral Health Condition, Fiscal Year 2014 SUD (Adults) SMI SED SED SPMI SUD (Youth) 12 Page