On the Road to Mental Health

The California Mental Health Services Authority (CalMHSA) — a coalition of nearly all of California's counties — has implemented an ambitious, first-of-its-kind set of statewide prevention and early intervention (PEI) initiatives with the broad goals of reducing mental illness stigma and discrimination, preventing suicide, and improving student mental health. The initiatives took a public health, population-based approach to developing and implementing many PEI resources and programs, beginning in 2011. This implementation was guided by a comprehensive strategic plan informed by evidence regarding the effectiveness of PEI approaches and carefully developed through a process that involved diverse stakeholders. The CalMHSA PEI initiatives were funded by Proposition 63, the Mental Health Services Act.

CalMHSA selected the RAND Corporation to conduct an independent evaluation of the PEI initiatives. This brief reviews RAND's key evaluation findings. Overall, results show that many program components were successfully implemented and achieved their intended impacts in the short term. Continued dissemination and support of effective programs will be required to sustain short-term gains and to observe longer-term impacts on the mental health, quality of life, and productivity of Californians.

Social Marketing Campaigns Were Associated with Reduced Mental Illness Stigma and Increased Confidence to Intervene

CalMHSA implemented two campaigns: "Each Mind Matters" is a stigma-reduction social marketing campaign that includes branded promotional items (ribbons, bracelets, etc.) that aim to get Californians talking about mental illness; documentary screenings; the EachMindMatters.org website, which provides stigma-reduction resources; the ReachOut.com online forum, which provides support for teens and young adults; and theatrical productions for youth. "Know the Signs" is a mass media suicide-prevention effort that uses billboards and advertisements to encourage people to visit the campaign website (www.suicideispreventable.org) to learn about suicide warning signs and resources.

• "Each Mind Matters" and other stigma-reduction campaign activities targeted at adults reached 45 percent of California adults in 2013 or 2014, and reach is growing. Over the two years evaluated, more Californians said that they were willing to socialize with, live next door to, or work closely with people experiencing mental illness, and those experiencing mental illness symptoms were more likely to receive treatment.
• "Know the Signs" reached 56 percent of adults in California. Those who were exposed to the campaign reported being more confident in intervening with those at risk of suicide. An expert panel found that the campaign is aligned with best practices and holds it in high regard.

Trainings Increased Knowledge and Improved Attitudes Toward Mental Illness

Training efforts targeted many different kinds of audiences, such as community members; K–12 and higher-education students, parents, and educational staff; health care providers; and other "gatekeepers" who interact with those with mental illness. Goals included providing social contact with people with mental illness to reduce stigma and providing knowledge, such as skills needed to intervene with those with mental health needs. For instance, one program trained individuals to deliver Applied Suicide Intervention Skills Training (ASIST), who in turn trained gatekeepers — those whose jobs may put them in a position to interact with people at risk for suicide — in how to recognize and help those at risk. RAND observed some ASIST training sessions and found that new trainers demonstrated high fidelity to the prescribed training. Tens of thousands of trainings were conducted, with positive results, including the following:

• Participants in educational training programs conducted by the National Alliance on Mental Illness reported immediate improvements in knowledge about mental health and attitudes toward people with mental health challenges, including greater willingness to socialize with, live next door to, and work closely with individuals with mental illness.
• Other training programs aimed at reducing stigma and discrimination, such as those carried out by Mental Health America of California and Disability Rights California, similarly influenced a variety of stigma-related attitudes, beliefs, and intentions among attendees.
• Attendees at educational trainings for faculty, students, and staff at the K–12 and higher-education levels reported improvements in their confidence to refer and intervene with students who appeared to be emotionally distressed.

Hotlines Provided Support to Those at Risk for Suicide

CalMHSA invested in 12 suicide-prevention hotlines to support improvements in their reach and capacity. For example:

• One suicide-prevention hotline was created; one was rebranded to accept calls from a larger geographic region; three "warmline" services for noncrisis calls were created or expanded; and chat or text crisis support was created or expanded by three crisis centers.
• Live monitoring of 241 calls made to ten suicide-prevention hotlines showed that those answering the calls exhibited predominantly positive behaviors with callers and that 43 percent of callers experienced reductions in distress, as measured by an objective rater, over the course of the calls (the remainder did not experience any change or were not in distress at the beginning of the call).

PEI Programs Had a Positive Return on Investment

The evidence suggests that some PEI programming not only pays for itself but also yields money back to the state, when future economic benefits are projected.

• The training of ASIST trainers was projected to prevent suicide attempts and deaths and return money to the state through averted Medi-Cal health care costs and increased state income tax revenue.
• Distressed individuals who were exposed to the "Each Mind Matters" campaign were more likely to seek treatment, which should produce a positive return on investment for the state in terms of higher productivity and employment.
• PEI programs in California's public universities and colleges are projected to increase engagement in mental health treatment and thus increase graduation rates, in turn leading to higher lifetime earnings and a high return on investment to the state.

Evaluation Findings Enhanced Understanding of California's Mental Health PEI Needs and Priorities for Ongoing Intervention

Although CalMHSA's programs have made a great deal of progress thus far, there is an ongoing need for mental health PEI efforts in California. RAND's evaluation identified areas in which continued, targeted efforts are needed:

• Mental illness stigma and discrimination remain widespread. Among those who have recently experienced symptoms of mental illness, more than two-thirds would definitely or probably hide a mental health problem from coworkers or classmates, and more than one-third would hide it from family or friends. Nine out of ten of those who reported a mental health problem in the past year reported experiencing discrimination as a result.
• Asian American adults reported relatively high levels of stigmatizing attitudes toward individuals with mental illness and low rates of mental health treatment.
• Latinos were also in relatively high need of efforts to reduce mental illness stigma. In particular, Latinos with mental illness who primarily speak Spanish need encouragement to get into treatment.
• Young adults hold some of the least-stigmatizing attitudes toward mental illness and are more likely to know someone with mental illness, but they are less likely to feel that they know how to help, suggesting the importance of programming that educates this group about how to be supportive and how to connect people to the resources that they need.
• The highest suicide rates are in California's rural counties in the northern region, but the burden, measured by the number of lives lost to suicide, is highest in the more-populous southern counties, suggesting that suicide prevention approaches need to focus on the entire state.
• One out of five higher-education students reported probable serious psychological distress, and high numbers of students reported impairment in academic performance associated with anxiety or depression. However, four out of ten higher-education faculty and staff did not know how to help connect distressed students to the services that they needed.
• On campuses that are perceived to be supportive of mental health issues, rather than stigmatizing, students were over 20 percent more likely to receive treatment.

Summary and Considerations for the Future

RAND's evaluation of CalMHSA's statewide PEI initiatives to date shows that extensive programmatic capacities and resources were successfully developed and rolled out. Implementation included dissemination of two major social marketing campaigns, numerous trainings throughout the state, distribution of extensive online and print materials, and regionally tailored improvements in hotline capacity.

The evaluation examined short-term impacts of key program activities and generally found that individuals reached by programs showed changes in attitudes, knowledge, or behavior consistent with the intent of the program. Furthermore, the reach to target audiences was impressive, given the relatively short period over which the programs were developed and implemented. For some program activities, RAND used evaluation findings and prior literature to project future societal benefits and costs; these simulations suggest a positive return on California's investment in the PEI programs, even under conservative assumptions.

Statewide PEI programs provide an important opportunity for California to move toward a comprehensive population-based public health approach to mental health, as recommended by the Centers for Disease Control and Prevention and the President's New Freedom Commission on Mental Health. To inform planning and improve PEI programs over time, ongoing population surveillance and performance monitoring are essential. Public health literature and experience suggest that coordinated and sustained PEI efforts over several decades are often required to substantially effect changes in public knowledge, attitudes, and behavior and create shifts in social norms and institutions that improve health (e.g., regarding HIV/AIDS, cigarette smoking, and mental illness stigma).

The CalMHSA statewide PEI initiatives represent a first step toward a strategic and effective public health approach to mental health in California. RAND's evaluations of these initiatives so far has found that many programs show promise toward achieving the initiatives' broader goals, and the evaluations have highlighted several important targets for outreach and education in California's diverse communities. However, RAND evaluators suggest that California's progress toward broader goals — including reducing suicide, improving early receipt of needed services, reducing discrimination, and avoiding some of the negative social and economic consequences associated with mental illness — will require a long-term commitment to a coordinated PEI strategy that is continuously informed by population needs, evidence regarding promising and best practices, and indicators of program performance and quality.

CalMHSA

The California Mental Health Services Authority (CalMHSA) is an organization of county governments working to improve mental health outcomes for individuals, families, and communities. Prevention and early intervention programs implemented by CalMHSA are funded by counties through the voter-approved Mental Health Services Act (Prop. 63). Prop. 63 provides the funding and framework needed to expand mental health services to previously underserved populations and all of California's diverse communities.