Behavioral Health Careers: Changes Coming Heather A. Flynn, PhD Associate Professor Vice Chair for Research Florida State University College of Medicine

Behavioral Health Integration in Health Care Behavior change is at the heart of most costly and chronic health care concerns (heart disease, obesity, depression, cancers, diabetes, liver disease, respiratory problems) Payers (e.g. Center for Medicaid and Medicare Service; Congress) are most interested in driving down costs for these conditions.

Leading causes of burden of disease (DALYs) by WHO Region of the Americas, 2004 Disease / InjuryDALY (millions) Unipolar depressive disorders10.8 Violence6.6 Ischaemic heart disease6.5 Alcohol use disorders4.8 Road traffic accidents4.6 Diabetes mellitus4.1 Cerebrovascular disease4.0 Lower respiratory infections3.6 COPD3.1 Congenital anomalies2.9

Health Behaviors Linked to Health Outcomes Substance Use Diet / Exercise Treatment / referral / medication compliance Making and appointment Specific interpersonal behavior changes Risk behaviors (HIV; pregnancy)

Nearly half (48.2%) of all causes of mortality in the U.S. are due to behavioral factors Determinants of health:

1. Health and disease are determined by dynamic interactions among biological, psychological, behavioral, and social factors. These interactions occur over time and throughout development. Cooperation and interaction of multiple disciplines are necessary for understanding and influencing health and behavior. 6 Health & Behavior Findings (IOM, 2001)

2. Psychosocial factors influence health directly through biological mechanisms and indirectly through an array of behaviors. e.g. Socioeconomic status Social inequalities Social networks and support Work conditions Depression Anger Hostility 7 Health & Behavior Findings (IOM, 2001)

3. Behavior can be changed Behavioral interventions can successfully teach new behaviors and attenuate risky behaviors Maintaining behavior change over time is a greater challenge 4. Individual behavior, family interactions, community and workplace relationships and resources, and public policy all contribute to health and influence behavior change 8 Health & Behavior Findings (IOM, 2001)

5. Initiating and maintaining a behavior change is difficult. Easier to generalize a newly learned behavior than to change existing behavior “prevention is easier than cure” 6. The goals of public health and health care are to increase life expectancy and improve health related quality of life You can modify risk behavior 9 Health & Behavior Findings (IOM, 2001)

7. Changing unhealthy behavior is not simply a matter of “will power”. Individual behavior has biological underpinnings and consequences Influenced by social and psychological contexts in which it occurs 10 Health & Behavior Findings (IOM, 2001)

Typical Morning in Primary Care 56 y.o. diabetes uncontrolled 19 y.o. smoker 33 y.o. multiple somatic complaints 1 y.o. otitis media 67 y.o. insomnia 7 y.o. sinusitis 52 y.o. hypertension 45 y.o. tinnitus 38 y.o. asthma 29 y.o. chest pain 11

The 2010 Patient Protection and Affordable Health Care Act (ACA) Expansion of Medicaid and coverage in general Parity for Behavioral Health and Substance Abuse Co-location, integration of behavioral health / substance abuse with primary care Patient-centered medical home (may include Community Mental Health sites)

What does this mean for Behavioral Health Careers? Significantly increased staffing / personnel to deliver behavioral health interventions Nurses, Physician assistants, MSW’s Staff to collect, monitor and manage a new array of health care outcomes (Program evaluation) Greater implementation of Evidence-based behavioral health treatments (MI, Assertive Community Treatment, CBT)

Areas of Behavioral Health Careers Clinical Bachelor, Masters, Doctoral, Nursing, Physician Assistant Primary Health Care settings Public or Private health centers / organizations Substance Abuse Correctional Child Development / Disorders Research Bachelor, Masters, Doctoral, Nursing Laboratory – clinical – community Teaching University / College – typically PhD level Training / consultation in evidence-based behavioral approaches

NIH Research Funding Priorities Comparative effectiveness research. e.g. Diabetes Prevention Program demonstrated substantially better benefits of exercise and life- style changes over medication in preventing the onset of diabetes. Prevention and personalized medicine. Advances in pinpointing individual genetic and environmental risk factors for disease now make it possible to focus prevention strategies more effectively. Also, both retrospective and prospective analyses of how individual information about disease risk actually alters health behaviors and clinical outcomes Health disparities research. The health of racial and ethnic minorities, people living in poverty, and other disadvantaged groups in the US is substantially worse than the health of the overall population. Any successful reform of the health-care system will require attention to these groups. Using new and powerful tools to disaggregate environmental and genetic contributions, NIH will seek to pinpoint causes of health disparities and to point the way toward solutions. Health research economics. Further precision is needed in assessing the economic value of research initiatives, especially those that are large and expensive. NIH plans to initiate a grants program to encourage development and application of more rigorous models.

Themes Across Major Funding Agencies: NIH Programs &Institutes, AHRQ, SAMHSA, PCORI Patient-centered themes Science of Health Behavior Change / Prevention Personalized medicine (Intervention moderators) Data sharing and mining Bioethics / Ethics in Research Health Disparities