Developing Regional Mental Health Priorities: Mixed-Methods Needs Assessment of Eight States in the Southeastern United States

The purpose of the needs assessment was to examine Region 4’s demographic, clinical, and public mental health system characteristics; available mental health–related training; and the mental health priorities, initiatives, and needs of our states (4). We collected data through a mixed-methods approach that included document review, quantitative analysis of publicly available data, and stakeholder interviews. The Southeast MHTTC team contributing to the data collection and analysis included the evaluation director, two project coordinators, a data analyst, and two graduate students, who worked closely with the center’s director, deputy director, and training director. Data collection and analysis occurred from November 2018 through May 2019. For the document review, we gathered information about SMHAs and financing for mental health services from the websites of SMHAs and other state agencies as well as from publicly available reports and resources. We conducted targeted Internet searches to compile a list of available mental health–related training and resources in each state. To examine the location and characteristics of outpatient mental health facilities in the region, we analyzed data from the SAMHSA Treatment Locator Database (5) and the Health Resources and Service Administration’s Area Health Resources Files (6). We held a series of conversations with state mental health commissioners, and we conducted interviews with key SMHA leaders. In total, we spoke to 22 stakeholders (1–4 per state). The purpose of the key informant interviews was to gather in-depth information about the structure of the state mental health system; the SMHAs’ priorities, initiatives and programs, and areas of need; and the SMHAs’ preferences for technical assistance. We took detailed notes during each meeting, which were then analyzed for common themes.

We examined the findings from the three data sources to identify which topics were of importance to SMHAs, areas in which the SMHAs were working, and areas of need. We subsequently shared the identified regional priority areas with the eight-member Southeast MHTTC Advisory Board—composed of state mental health commissioners, chiefs of staff, and other state mental health leaders—for additional review and input. Advisory board members confirmed that the identified priorities aligned with their SMHAs’ aims and provided feedback that we incorporated into our report. We shared the final report with the advisory board and with other key stakeholders in the region.

To gain a better understanding of HHS Region 4, we examined the characteristics of the region and the eight SMHAs to identify similarities and differences across states. The demographic profiles of the Region 4 states vary greatly in total population, racial and ethnic diversity, and percentage of the population living in rural areas. Compared with the United States overall, the southeastern states tend to have a larger proportion of the population living at or below the federal poverty level, as well as higher rates of people who are unemployed and uninsured (7). The percentages of people with a mental illness, substance use disorder, or suicidal ideation in the Region 4 states are generally comparable to those of the United States overall (8).

Across the region, the public mental health systems vary in organization, structure, financing, and services offered. A majority of SMHAs operate as independent state departments (Alabama, Georgia, Mississippi, South Carolina, and Tennessee), but some are housed under other state agencies (i.e., Health Department in Kentucky, Department of Human Services in Florida, and Department of Health and Human Services in North Carolina). Most SMHAs (except for those in North Carolina and South Carolina) are responsible for substance abuse services, and half provide services for individuals with intellectual and developmental disabilities (Alabama, Georgia, Kentucky, Mississippi). All of the SMHAs provide community-based mental health services and support as well as inpatient care in psychiatric hospitals. The SMHAs fund and administer community-based mental health services through one or more mechanisms, including direct provision of services, provision of funding but not operation of SMHA service provider organizations, and provision of funding to local authorities to oversee and manage service provision. According to SAMHSA data from 2014 (9), Region 4 states served approximately 1.3 million clients and expended $4.4 billion.

Like states across the country, Region 4 states experience shortages in the psychiatric workforce, particularly for adult and child psychiatrists, mental health counselors, social workers, and school psychologists (10). Similar to the United States overall, most counties in Region 4 (61%) are designated as complete mental health professional shortage areas, and 55% of counties in the region have fewer than one practicing psychiatrist per 100,000 residents. Across the Region 4 states, SMHAs, health care service providers, nonprofit organizations, and other organizations provide a variety of training opportunities for the mental health workforce and other professionals (4).

Of the 24 topics that arose during the stakeholder interviews and the document review, we identified six regional priority areas: mental health workforce, school-based mental health, suicide prevention, peer workforce, criminal justice and mental health, and supported housing. These priority areas are being used to inform the training and technical assistance activities of the Southeast MHTTC. (A table summarizing the priority areas is available in the online supplement accompanying this column.)

This needs assessment provided a valuable opportunity to understand the state mental health landscape not only in each of the eight southeastern states but also across the region as a whole. Our mixed-methods approach yielded key information from each data source about the region’s mental health initiatives, assets, and needs. Engagement of stakeholders, particularly the SMHA leaders, proved essential, both throughout the needs assessment process and as we continue to use the findings to inform the Southeast MHTTC’s activities.

Across Region 4, SMHAs implement a variety of initiatives and services to address the mental health needs of individuals in their states. However, each of the states experiences challenges, most of which are shared by other states (e.g., workforce shortages and financing). Through the needs assessment process, we identified six regional priority areas in which most or all states had current initiatives but also gaps between available services and the desired level of programming. Each state has key initiatives and assets that can serve as examples for other states in the region.

Identification of common priorities and challenges for SMHAs in the Southeast presents an opportunity for these states to converge on and discuss common topics and to facilitate shared learning. SMHAs could benefit from the opportunity to learn from each other, problem solve together, and consider ways to adapt new approaches to their states or leverage resources across states. In addition to allowing states to connect with each other, the Southeast MHTTC can coordinate opportunities for dialogue and training across the region. Group learning models, such as learning collaboratives, provide a framework for supporting discussion and sharing of information, organizational-level change, and implementation of evidence-based practices (11). The Southeast MHTTC has developed an array of strategies, including webinars, in-person training sessions, intensive coaching, and learning collaboratives, to address each of the priority areas identified in the needs assessment.

We identified several lessons from engaging in the needs assessment. This process demonstrated the value of using quantitative and qualitative data sources to identify regional strengths, challenges, and priorities. The information we obtained can be used in strategic planning to support the region. For example, the results can be used to facilitate shared learning across states and to engage state leaders, who may be especially interested to learn about examples from other states with similar challenges and constraints. Additionally, the priority areas identified can continue to inform the creation of training and programming targeted to regional needs. The needs assessment findings and mental health priority areas can serve as a foundation on which to foster collaborative engagement in the region.

The authors acknowledge the contributions of the Southeast Mental Health Technology Transfer Center (MHTTC) advisory board and the Southeast MHTTC team members.