Changing the Conversation: Challenges and Opportunities Pamela S. Hyde, J.D. SAMHSA Administrator Federal Partners Meeting on the Borderline Personality Disorder Rockville, MD • November 9, 2011

FOCUS AREAS FOR TODAY’S DISCUSSION 3 CONTEXT: DRIVERS OF CHANGE FOCUS  PREVENTION, TREATMENT, RECOVERY NATIONAL DIALOGUE ON ROLE OF BH IN PUBLIC LIFE

Federal Domestic Spending DRIVERS OF CHANGE 4 EMERGING SCIENCE Health Reform State Budget Declines Federal Domestic Spending

STAYING FOCUSED DURING CHANGE 5

SAMHSA’S STRATEGIC INITIATIVES 6 AIM: Improving the Nation’s Behavioral Health (1-4) AIM: Transforming Health Care in America (5-6) AIM: Achieving Excellence in Operations (7-8) 1. Prevention 2. Trauma and Justice 3. Military Families 4. Recovery Support 5. Health Reform 6. Health Information Technology 7. Data, Outcomes & Quality 8. Public Awareness & Support

CHRONIC DISEASES: GLOBAL IMPACT 7 World Economic Forum: Global economic impact of 5 diseases could reach $47 trillion over the next 20 years MH will account for $16 trillion – a third of cost Cancer Diabetes Mental Illness Heart Disease Respiratory Disease

IMPACT ON HEALTH CARE COSTS 8 By 2020, M/SUDs will surpass all physical diseases as a major cause of disability worldwide U.S. 2006: Mental disorders were 3rd most costly health condition behind heart conditions and injury-related disorders Mental illness and heart diseases alone account for almost 70 percent of lost output/productivity M/SUDs: almost ¼ of all adult stays in community hospitals 30-44 percent of all cigarettes consumed in the U.S. are by individuals with M/SUDs Up to 83 percent of people w/SMI are overweight or obese

Borderline Personality Disorder (BDP)- Common, COMPLEX & MISUNDERSTOOD 9 An estimated 18 million Americans will develop BPD in their lifetimes. This makes BPD more common than schizophrenia and bipolar disorder. Individuals are frequently misdiagnosed and receive inappropriate treatment. They often have co-occurring mental and substance use disorders.

10 LEADING CAUSES OF DEATH United States, 2008, All Races, Both Sexes RANK ALL AGES 1. Heart Disease: 616,828 2. Malignant Neoplasms: 565,469 3. Chronic Low Respiratory Disease: 141,090 4. Cerebro-vascular : 134,148 5. Unintentional Injury: 121,902 6. Alzheimer's Disease: 82,435 7. Diabetes Mellitus: 70,553 8. Influenza & Pneumonia: 56,284 9. Nephritis: 48,237 10. Suicide: 36,035 WISQARSTM Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System

DAILY DISASTER OF UNPREVENTED AND UNTREATED M/SUDs 11 Any MI: 45.1 million 37.9 % receiving treatment SUD: 22.5 million 11.6 % receiving treatment Diabetes: 25.8 million 84 % receiving treatment Heart Disease: 81.1 million 74.6 % receiving screenings Hypertension: 74.5 million 70.4% receiving treatment

TOUGH REALITIES 12 12 The suicide rate of people with major depression is 8 times that of the general population. Individuals diagnosed with BPD have a suicide rate 50 TIMES that of the general population.* The estimated rate of self-injury for individuals with BPD is 60 to 80 percent. *separate study

TOUGH REALITIES AGE 14-18 AGE 18 AND ↑ HAD SERIOUS THOUGHTS OF SUICIDE 13 AGE 14-18 AGE 18 AND ↑ HAD SERIOUS THOUGHTS OF SUICIDE 2.9 million, 13.8% 8.4 million, 3.7% MADE A PLAN 2.3 million, 10.9% 2.2 million, 1% ATTEMPTED SUICIDED 1.3 million, 6.3% 1.1 million, .05% DIED BY SUICIDE >1,000 >36,000

MISSED OPPORTUNITIES = LIVES LOST 14 77 percent of individuals who die by suicide had visited their primary care doctor within the year. 45 percent had visited their primary care doctor within the month. 18 percent of elderly patients visited their primary care doctor on same day as their suicide. THE QUESTION OF SUICIDE WAS SELDOM RAISED…

NATIONAL ACTION ALLIANCE FOR SUICIDE PREVENTION 15 Priorities: Surgeon General’s NSSP Public Awareness High-risk populations

PREVENTION WORKS: 2009 IOM REPORT 16 Common risk & protective Factors Build emotional health in young children Prevent substance abuse, adolescent depression, conduct disorders Risk factors: biological, psychological, family, community, or cultural Protective factors: individual, family, school/community Signs evident 2‐4 years before disorder Intervene earlier, consistently, and across multiple institutions Parents, teachers, clergy, community Coordinate/collaborate at policy levels

TRAUMA IS PERVASIVE, DISABLING 17 Childhood traumas/difficulties potentially explain 32.4% of psychiatric disorders in adulthood February 2010 Archives of General Psychiatry Based on analyses of the National Comorbidity Survey Replication

CHILDREN ARE VULNERABLE 18 More than 6 in 10 U.S. youth have been exposed to violence within the past year; nearly 1 in 10 injured. Adverse childhood experiences (ACEs, e.g., physical, emotional, and sexual abuse, as well as family dysfunction) associated with mental illnesses, suicidality, substance abuse, and physical illnesses. 40% to 70% of individuals with BPD in inpatient and outpatient settings report childhood sexual abuse.

TREATMENT IS EFFECTIVE: EVIDENCE-BASED PRACTICES (NREPP) 19 Effective approaches to address trauma, common in individuals with BPD Dialectical Behavior Therapy (DBT) Reduces suicide attempts, hospitalization; increases retention in treatment Family Psychoeducation (SAMHSA EBP KIT) Helps improve family functioning Equips family members with coping skills Improves outcomes for person with BPD

PEOPLE RECOVER 20 Despite high rates of suicide and self-injury associated with BPD, the diagnosis has a positive prognosis. Up to three-quarters of individuals experience measurable improvement with treatment; many symptoms abate significantly.

RECOVERY: PROPOSED WORKING DEFINITION 21 Recovery from mental and substance use disorders is: A process of change through which individuals improve their health and wellness, live a self- directed life, and strive to achieve their full potential.

PROPOSED RECOVERY PRINCIPLES 22 Person-centered Occurs via many pathways Holistic Supported by peers Supported through relationships Culturally based and influence Supported by addressing trauma Involves individual, family and community strengths and responsibility Based on respect Emerges from hope

RECOVERY CONSTRUCT Individuals and Families HOME ↑ Permanent Housing 23 Individuals and Families HOME ↑ Permanent Housing COMMUNITY ↑ Peer/Family/ Recovery Network Supports PURPOSE ↑ Employment/ Education HEALTH ↑ Recovery TALKING POINTS: Issue Statement - Promoting individual, program, and system approaches to building recovery and resilience; developing services, information and partnerships to increase permanent supportive housing, supported employment and education and other recovery support services for persons with mental and substance use disorders; and reducing barriers to recovery for individuals with mental and substance use disorders. SAMHSA’s portfolio of programs (ATR, Recovery Oriented Systems of Care, 10 by 10 Wellness Campaign, Employment Summit) and evidenced based practice toolkits (supported employment, supported education, supportive housing) along with public awareness campaigns, surveillance and performance system, and partnerships will address the goal areas.

SAMHSA’S COMMITMENT 24 A NATIONAL DIALOGUE

PUBLIC HEALTH OR SOCIAL PROBLEM? 25 Public Health National Dialogue Health Needs of People & Communities Social Problem Insufficient Response Attention to Symptoms Individual Blame

TRAGEDIES Grand Rapids, MI Tucson, AZ 2011 – 8 Lost 2011 – 6 Lost 26 Grand Rapids, MI 2011 – 8 Lost Tucson, AZ 2011 – 6 Lost Asher Brown 2010 – 1 Lost 13 Year Old West Nickel Mines School, PA 2007 – 6 Lost Virginia Tech, VA 2007 - 33 Lost Red Lake Band of Chippewa, MN, 2005 – 10 Lost Columbine High School, TX 1999 - 15 Lost

FROM EVENTS TO ASSUMPTIONS . . . 27 Individual Blame Misunderstanding Moral Judgment Discrimination Prejudice Social Exclusion

LEADING TO: INSUFFICIENT RESPONSES 28 Increased Security & Police Protection Tightened Background Checks & Access to Weapons Legal Control of Perpetrators & Their Treatment More Jail Cells & Homeless Shelters Institutional/System/ Provider Oversight

WHAT AMERICANS BELIEVE 29 66 percent believe treatment and support can help people with mental illness lead normal lives 20 percent feel persons with mental illness are dangerous to others Two-thirds believe addiction can be prevented 75 percent believe recovery from addiction is possible 20 percent would think less of a friend/relative if they discovered that person is in recovery from an addiction 30 percent would think less of a person with a current addiction

SO, HOW DO WE CREATE . . . 30 A national dialogue on the role of BH in public life With a public health approach that: Engages everyone – general public, elected officials, schools, parents, community coalitions, churches, health professionals, researchers, persons directly affected by mental illness/addiction & their families Is based on data, facts, science, common understandings/messages Is focused on prevention (healthy communities) Is committed to the health of everyone (social inclusion)

WE WANT TO CHANGE THE CONVERSATION FROM: 31 “Too lazy , too drunk to work” “Too dangerous to live next door” “Too sick to have insight” “Too ill to participate in treatment decisions”

TO: “Too talented to waste” 32 “Too talented to waste” “Too much potential to lock up or keep out” “Too much insight to ignore” “Too costly NOT to support prevention and recovery”

HELP US CHANGE THE CONVERSATION! Behavioral Health is Essential to Health! Prevention Works! People Recover! Treatment is Effective! 33 National Dialogue