Behavioral Health: Public Health Challenge Public Health Opportunity Pamela S. Hyde, J.D. SAMHSA Administrator New Orleans, LA • January 25, 2012

MAKING THE CASE 3 BEHAVIORAL HEALTH: AMERICA’S #1 PUBLIC HEALTH CHALLENGE GLOBAL & DOMESTIC IMPACTS CHANGING THE HEALTH CARE FIELD

BEHAVIORAL HEALTH IS ESSENTIAL TO HEALTH 4 By 2020, mental & substance use disorders (M/SUDs) will surpass all physical diseases as a major cause of disability worldwide One-half of U.S. adults will develop at least one mental illness in their lifetime U.S. 2006: M/SUDs 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

BEHAVIORAL HEALTH IMPACTS 5 2+ million Americans report mental/emotional disorders as the primary cause of their disability (per CDC) Depression is the most disabling health condition worldwide; SA is # 10 M/SUDs: 24 percent of pediatric primary care office visits & almost ¼ of all adult stays in community hospitals Years Lost Due to Disability in Millions (High-Income Countries – World Health Organization Data)

PREMATURE DEATH AND DISABILITY 6 People with M/SUDs are nearly 2x as likely as general population to die prematurely, often of preventable or treatable causes BH conditions lead to more deaths than HIV, traffic accidents + breast cancer More deaths from suicide than from HIV or homicides Half the deaths from tobacco use are among persons with M/SUDs 5,000 deaths each year attributable to underage drinking CDC, National Vital Statistics Report, 2009

10 Leading Causes of Death, United States 2008, All Races, Both Sexes 7 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

TOUGH REALITIES AGE 14-17 AGE 18 AND ↑ HAD SERIOUS THOUGHTS OF SUICIDE 2.9 million, 13.8% (2009) 8.7 million, 3.7% (2010) MADE A PLAN 2.3 million, 10.9% (2009) 2.5 million, 1.0% (2010) ATTEMPTED SUICIDE 1.3 million, 6.3% (2009) 1.1 million, 0.5% (2010) DIED BY SUICIDE >1,000 (2008) >35,000 (2008)

MISSED OPPORTUNITIES = LIVES LOST 9 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…

DAILY DISASTER OF UNPREVENTED AND UNTREATED M/SUDs 10 Any MI: 45.9 million 39.2 % receiving treatment SUD: 22.1 million 11.2 % 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

CHRONIC DISEASES: GLOBAL IMPACT 11 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

ECONOMIC IMPACT ON AMERICA 12 THE ECONOMY Estimated total societal cost of substance abuse in the U.S. is $510.8 billion per year Economic costs of mental, emotional, and behavioral disorders among youth ~ $247 billion Alcohol and drug abuse & dependence: ~ $263 billion in lost productivity costs per year Mental disorders: ~$94 billion in lost productivity costs per year

IMPACT ON PHYSICAL HEALTH 13 MH problems increase risk for physical health problems & SUDs increase risk for chronic disease, sexually transmitted diseases, HIV/AIDS, and mental illness Adults with SMI have shortened life spans and high co-morbidities 69 percent report at least one medical disorder 83 percent are overweight or obese Cost of treating common diseases higher when a patient has untreated BH problems Hypertension – 2x the cost Coronary heart disease – 3x the cost Diabetes – 4x the cost M/SUDs rank among top 5 diagnoses associated with 30-day readmission; one in five of all Medicaid readmissions 12.4 percent for MD 9.3 percent for SUD

IN LOUISIANA….. Of persons 12 or older in LA: 14 Of persons 12 or older in LA: 7.2% (259,000) used an illicit drug in the past month, vs. 8.4% nationally 2.9% (105,000) abused or were dependent on illicit drugs, vs 2.8% nationally 7.0% (253,000) abused or were dependent on alcohol, vs 7.4% nationally Of persons 18 or older in LA: 19.7% had any form of mental illness, equal with the national average 4.8% had serious mental illness, vs. 4.6% nationally 3.1% had thoughts of suicide, vs. 3.7% nationally Providers 163 total SA treatment facilities, 119 were outpatient 158 total MH facilities, 78 were outpatient Based on 2008 to 2009 National Survey on Drug Use and Health (NSDUH) data.

IMPACT OF TRAUMA Childhood trauma is extensive 15 Childhood trauma is extensive > 6 in 10 U.S. youth have been exposed to violence within the past year Nearly 1 in 10 injured 695,000 children were victims of maltreatment in 2010 Adverse childhood experiences (ACEs) are associated with MI, suicidality, substance abuse, and physical illnesses ACEs = physical, emotional, and sexual abuse; family dysfunction, disasters and their aftermath, poverty, domestic violence, events leading to involvement with criminal justice or child welfare systems, neighborhood disorganization Potentially explain 32.4 percent of M/SUDs in adulthood Brain impacts: chronic acute stress in early childhood can lead to: Future health problems (including depression & other BH problems) Damage to hippocampus Smaller physical size of developing brain

PREVENTION WORKS 16 2009 IOM Report Preventing Mental, Emotional, and Behavioral Disorders among Young People: Progress & Possibilities Half of all adult mental, emotional and behavioral (MEB) disorders were first diagnosed by age 14 and three-fourths by age 24 MEB disorders among youth as commonplace as a fractured limb Individual, family and community risk and protective factors can be addressed and are effective Common, early, consistent, multi-sector, continuous, community-based public health approaches work Environmental, policy, culture and individual approaches work

TRAUMA & JUSTICE: Homelessness 17 ~ 46 percent of people who are homeless have a mental illness; 64 percent have an alcohol or substance use disorder Among inmates who had MH problems, 13 percent of state prisoners and 17 percent of jail inmates said they were homeless in the year before their incarceration Providing housing for persons with mental illnesses who are homeless reduces criminal justice involvement by 38 percent (jail days) and 84 percent (prison days)

TRAUMA & JUSTICE: Jail Diversion 18 > Half of all inmates have MH problem; 6 in 10 have SA problem; one-third have both When done right, jail diversion works: Divertees use less alcohol and drugs (53 percent at 6 months) Have fewer arrests after diversion compared to 12 months before (2.3 vs. 1.1) Fewer jail days (52 vs. 35) Meets community needs: 3 out of 4 SAMHSA jail diversion programs keep operating after federal funding ends Goal—Create prevention prepared communities where individuals, families, schools, workplaces, and communities take action to promote emotional health and prevent and reduce mental illness, substance abuse including tobacco, and suicide across the lifespan. Fast Facts By 2020, as a major cause of disability, behavioral health disorders will surpass all physical diseases world-wide 2.9 million persons aged 12 or older used an illicit drug for the first time; almost 8,000 initiates per day ½ of all lifetime cases of mental illness begin by age 14 and ¾ by age 24 The latest epidemiologic data available indicate that from 15% (9.5 million) to 19% of the nation’s approximately 63 million children and youth suffer from emotional or other problems that warrant mental health treatment Young people with major depressive episode are twice as likely to take 1st drink or use drugs for the 1st time Among the 14 million adults aged 21 or older who were classified as having past year alcohol dependence or abuse, more than 13 million (95%) had started drinking alcohol before age 21 Over 1.1 million American adults attempted suicide and over 8 million seriously considered suicide More than 33,000 suicides occurred in the U.S. equaling 91 suicides per day; one suicide every 16 minutes

IN AN ENVIRONMENT OF CHANGE 19 EMERGING SCIENCE Health Reform State Budget Declines Federal Domestic Spending

THE UNINSURED Uninsured population – 37.9 M (<400% FPL) 20 Uninsured population – 37.9 M (<400% FPL) 18 M Medicaid eligible 19.9 M Health exchange eligible 11.02 M (29 percent) have behavioral health conditions Among Medicaid eligible population (133% FPL & below) 7.0 percent with a serious mental illness 14.2 percent with a substance use disorder Among exchange eligible population (134% - 399% FPL) 6.0 percent with a serious mental illness 14.6 percent with a substance use disorder

HEALTH REFORM: AFFORDABLE CARE ACT Major drivers More people will have insurance coverage Medicaid will play a bigger role Focus on primary care and coordination with specialty care Major emphasis on home and community based services and less reliance on institutional care Rethink what is offered as a benefit Outcomes: improving the experience of care, improving the health of the population and reducing costs

HEALTH REFORM: AFFORDABLE CARE ACT 22 Dual disorders the expectation, not the exception 50 percent Medicaid beneficiaries w/ disabilities also have psychiatric illness Annual Medicaid per capita health costs three to four times higher for disabled beneficiaries with co-occurring BH condition Dual eligibles represent 40 percent Medicaid spending Risk-based comprehensive managed care 66 percent Medicaid beneficiaries enrolled now 80 percent predicted for 2014

WHAT’S NEXT? Medicaid expansion & health exchanges – 1/1/14 23 Medicaid expansion & health exchanges – 1/1/14 Simplified Medicaid eligibility Enrollment Essential health benefits (state choices) More primary/behavioral health integration Increasing parity

BEHAVIORAL HEALTH – Public Health or Social Problem? 24 Public Health Social Problem Insufficient Response Attention to Symptoms Individual Blame National Dialogue Health Needs of People & Communities

TRAGEDIES Grand Rapids, MI Tucson, AZ 2011 – 8 Lost Asher Brown 25 Grand Rapids, MI 2011 – 8 Lost Tucson, AZ 2011 – 6 Lost Asher Brown 2010 – 1 Lost 13 yrs old West Nickle 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 26 Individual Blame Misunderstanding Prejudice Discrimination Moral judgment Social exclusion

LEADING TO INSUFFICIENT RESPONSES 27 Increased Security & Police Protection Tightened Background Checks & Access to Weapons Legal Control of Perpetrators & Their Treatment More Jail Cells & Homeless Shelters & JJ Facilities Institutional/System/ Provider Oversight

WHAT AMERICANS KNOW Most Know or Are Taught: 28 Most Know or Are Taught: Basic First Aid and CPR for physical health crisis Universal sign for choking; facial expressions of physical pain; basic terminology to recognize blood and other physical symptoms of illness and injury Basic nutrition and physical health care requirements Where to go or who to call in an emergency

WHAT AMERICANS DON’T KNOW 29 Most Do Not Know and Are Not Taught: Signs of suicide, addiction or mental illness or what to do about them or how to find help for self or others Relationship of behavioral health to individual or community health or to health care costs Relationship of early childhood trauma to adult physical and mental/substance use disorders

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)

HELP US CHANGE THE CONVERSATION! Behavioral Health is Essential to Health! Prevention Works! People Recover! Treatment is Effective! HELP US CHANGE THE CONVERSATION! 31 National Dialogue