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The Public Health/Primary Prevention Approach to Mental Health
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Mental Health America of Indiana is the largest state chapter of Mental Health America, and works for the mental health of all citizens and impacts those affected by mental illness and addiction through public education, advocacy, direct service, and public health reform.
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Brief History of Community Mental Health
Move people out of mental institutions and into the community, based on concept of “moral treatment” from Pinel, 1700s “the insane came to be regarded as normal people who had lost their reason as a result of severe psychological stress.” First national mental health advocacy organization (now Mental Health America) was established by Clifford Beers, a formerly hospitalized person with a mental illness. 1949 – Approval of chlorpromazine (Thorazine), and discovery that lithium treats mania 1963 – Community Mental Health Center Act signed by President Kennedy, mostly unfunded mid 60’s – Medicare/Medicaid offered some funding for care – partial hospitalization Timeline, brief history of treatment approaches and legislation over time
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Brief History of Community Mental Health
1980 – National Mental Health Service Systems Act – unfunded, then eliminated in 1981– “transitional institutionalization” to nursing homes, jails or prisons, boarding homes, foster care. LA county jail “largest psychiatric hospital in the country” 1996 – State hospital populations to 62,000 from 5.5M; managed care Late 90s to 2000 –symptom control rehab recovery 2003 – President’s New Freedom Commission on Mental Health 2008 – Parity Act: equal payment for medical and mental health 2010 – Affordable Care Act 2015 – HIP 2.0.
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The Impact of Mental Health Disorders is Enormous
By 2020, mental health disorders will surpass all physical diseases as a major cause of disability worldwide. In 2015, an estimated 43.8 million adults aged 18 and older in the United States had a diagnosed mental illness, and 10 million had a serious mental illness. Two million youth aged 12 to 17 had a major depressive episode during the past year. In 2014, an estimated 24.6 million Americans aged 12 and older needed treatment for substance use. Serious mental illness cost America $193.2 billion in lost earnings last year.
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Cost of Health Complexity
100 90 80 70 60 50 40 30 20 10 % of Patients Patient Type % of Costs Acute Illness Self-resolving illness Low grade acute illness Low 1/3 Serious Chronic Illness Chronic diseases Moderate to severe acute illness Health Complexity Multiple diagnoses Physical & mental health co-morbidity High health service use Impairment and disability Personal, social, financial upheaval Health system issues Medium 1/3 SMI/SUD population here High 1/3
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What Causes Mental Health and Addiction Issues?
Biopsychosocial factors Environmental Sociocultural
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THE PERFECT STORM!! SUICID Trauma Based MH/SUD
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While there are over 200 classified forms of
mental illness, the six (6) major categories of mental illness are: Anxiety Disorders Personality Disorders Mood Disorders Schizophrenia/Psychotic Disorders Dementias Eating Disorders
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Common Diagnosis Depression Major depression Bipolar disorder
Anxiety: Severe OCD, PTSD Schizophrenia Borderline personality disorder
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Co-Occurring Disorders
Diagnosis Lifetime Prevalence of Alcohol/Drug abuse or dependence Bipolar I 46.2% Bipolar II 39.2% Schizophrenia 33.7% Panic Disorder 28.7% Unipolar Depression 16.5% General Population 13.8%
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Army of Providers and Array of Services
Medical – MD, DO, APN, PA Psychotherapy – many flavors Case Management – link to community supports (e.g., housing, education) Crisis Services – manage emergency situations, arrange hospitalization, emergency commitments if needed Assertive Community Treatment (ACT) – mobile units that reach more severely ill patients Peer Services – individuals in recovery from their own mental health conditions helping others Vocational Support – assistance in preparing for, finding, and being successful in employment Substance Abuse Treatment – detox, outpatient groups, medication assistance Psychiatric Rehabilitation – develop skills to function in communities Clubhouse – self-support services Wellness Education – helps patients manage their symptoms at home A variety of services may be provided in public mental health settings
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Evidence-Based Practices
Medication Guidelines Dialectical Behavioral Therapy (DBT) Cognitive Behavioral Therapy (CBT) Supported Employment Assertive Community Treatment (ACT) Integrated Dual Diagnosis Treatment (IDDT) Family Psychoeducation Self Management – Stanford Self-Management, Health and Recovery Peer (HARP), Living Well, Whole Health Action Management (WHAM)* IMPACT model A variety of evidence based practices are used and are often required by regulatory agencies. There has been a proliferation of EBPs in the past decade that are extremely beneficial
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Recovery A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Four Dimensions: Health, Stable Home, Purpose and Community Supports Guiding Principles: Recovery emerges from hope, is person-driven, holistic, supported by peers and allies, culturally based, addresses trauma, involves strengths, occurs via many pathways, and is based on respect There is a lot to say about each of the guiding principles that is quite extensive. Refer attendee to the website for more information
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Recovery Rates – Severe Mental Illness
1/3 Full Recovery 1/3 Intermediate Outcome 1/3 Poor Outcome You are going to see more patients in the Intermediate and Poor range due to barriers PCPs will often see patients in the Intermediate and Poor Outcome category due to location of service in the public mental health sector
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Barriers to Mental Health Care
Lack of motivation, apathy Cognitive impairment Lack of perceived need for care Poverty There are a number of factors leading to struggles with getting the healthcare needed Cultural Stigma Poor social, communication skills Lack of access to care
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SAMHSA’S Vision A Nation That Acts On the Knowledge That:
Behavioral health is essential to health Prevention works Treatment is effective People recover
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A Public Health Model For Behavioral Health...
Universal – Focus on Population and Individual Health Health of any affects health of all – social inclusion Prevention First – Aim Is Healthy Individuals; Healthy Communities Preparation and activities to promote emotional health development and wellness, prevent disease/disorder, and react quickly and effectively to conditions that impact health
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Policies – Affecting the Environment In Which Health or Disease Occurs
Data & Information Driven – To Track and Improve Population-Based Health Status and Quality of Care/Life What drives health? What causes disease/disorder? What works to prevent, treat and support recovery – evidence-based approaches? Policies – Affecting the Environment In Which Health or Disease Occurs Laws, regulations, rules, norms, culture, conditions, expectations re individual and collective behavior for self and toward others
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Structures – Creating & Supporting Government and Community Infrastructure and Capacity
Departments, boards, committees, councils, commissions, coalitions, schools, universities Access – Assuring availability of right services when individuals, families, community need them Prevention, treatment and recovery supports Adequate, trained, and culturally capable workforce
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Behavioral Health is a Social Problem
Public dialogue about behavioral health is in a social problem context rather than a public health context Homelessness Crime/jails Child welfare problems School performance or youth behavior problems Provider/system/institutional/government failures Public tragedies Public (and public officials) often misunderstand, blame, discriminate, make moral judgments, exclude Ambivalence about worth of individuals affected and about the investment in prevention/treatment/recovery Ambivalence about ability to impact “problems”
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Leading to insufficient responses….
Increased Security & Police Protection Tightened Background Checks & Access to Weapons Legal Control of Perpetrators & Their Treatment More Jail Cells, Shelters, Juvenile Justice Facilities Institutional System Provider Oversight Leading to insufficient responses….
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Clinical Information Systems Self- Management Support
Public Health Model Resources and Policies Health System Community Health Care Organization Clinical Information Systems Self- Management Support Delivery System Design Decision Support Prepared, Proactive, Multidisciplinary Practice Team PRODUCTIVE INTERACTIONS Informed, Activated Patient/family Improved Outcomes
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Integrated Care The care that results from a practice team of primary care and behavioral health clinicians, working with patients and families, using a systematic and cost-effective approach, to provide patient-centered care for a defined population. This care may address: Mental health and substance abuse conditions Health behaviors (including their contribution to chronic medical issues) Life stressors and crisis Stress related physical symptoms Ineffective patterns of health care utilization Definition of Integrated Care from the Agency for Health Research and Quality
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Person-Centered Collaborative Care Opportunities
Behavioral Health in Primary Care Settings Primary Care in Behavioral Health Settings
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Multiple and Inconsistent Messages
Disease; disability; chronic medical condition; social reaction to difference; brain/genetic or environmental; treat the same as physical conditions; treat with a different psychosocial approach Substance abuse and mental illness stem from the same causes and often co-exist; or they are completely different fields and different diseases/conditions Behavioral health is and should be extraordinary; or should be the same as any other health condition
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Physical Health Behavioral Health What It Takes Reducing Risks
Nutrition Exercise Rest Good Genes Reducing Risks Hand-washing Covering cough Reducing food-borne illnesses Getting immunizations Taking universal precautions Avoiding unprotected sex What It Takes Understanding/managing emotions Managing stress Positive social relationships Reducing Risks Eliminating trauma Reducing chronic stress, esp. in childhood Promoting supportive relationships Informed parenting Teaching positive lifeskills
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Physical Health Behavioral Health Recognizing Signs
Temperature Cough Fever Pain Avoiding Behaviors That Increase Risks Addressing Symptoms Early detection – tests/screening Stop the bleeding and pain Save life first Recognizing Signs Suicidal thinking Depression and anxiety Post-traumatic stress Substance abuse Underage drinking or inappropriate amounts in adults Addressing Symptoms Early detection – screening/brief interventions Stop emotional pain Keep safe – for individual and for community
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Early Intervention Reduces Impact
1/2 of all lifetime cases of mental illness begin by age 14; 3/4 by age 24 On average, > 6 years from onset of symptoms of M/SUDs to treatment Effective multi-sectoral interventions & treatments exist Need treatment & support earlier Screening Brief interventions Coordinated referrals
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“Prevention emphasizes the avoidance of risk factors; promotion strives to promote supportive family, school, and community environments and to identify and imbue in young people protective factors, which are traits that enhance well-being and provide the tools to avoid adverse emotions and behaviors.”
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Secondary prevention is based on the idea that intervening early will decrease the likelihood of a disease, incidence, or occurrence, especially with high risk individuals.
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Tertiary prevention aims to lessen the impact of a disease, incidence, or occurrence that has long term effects.
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Primary prevention is concerned with preventing the onset of a disease or issue; it aims to eliminate the incidence. It involves interventions that are applied before there is any evidence of disease or issue.
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Experiences trigger or exacerbate BH problems
M/SUD CAN Be Prevented Experiences trigger or exacerbate BH problems Trauma, adverse childhood experiences, disasters and their aftermath, poverty, domestic violence, involvement with the criminal justice or child welfare systems, neighborhood disorganization and family conflict Addressing risk and protective factors is effective in reducing likelihood of M/SUDs
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Social Ecological Rings
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MH/SUD PROTECTIVE FACTORS
MH/SUD RISK FACTORS MH/SUD PROTECTIVE FACTORS Individual Factors Prenatal brain damage Easy temperament Prematurity Adequate nutrition Birth injury Above average intelligence Low intelligence Problem solving skills Chronic illness Internal locus of control Poor health in infancy Social competence Insecure attachment in infancy/childhood Social skills Low birth weight, birth complications Good coping style Difficult temperament Optimism Physical and/or intellectual disability Moral beliefs Poor social skills Values Low self-esteem Positive self regard Impulsivity Good physical health
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MH/SUD PROTECTIVE FACTORS
MH/SUD RISK FACTORS MH/SUD PROTECTIVE FACTORS Relationship Factors Relationship Factors Absence of either parent in childhood Attachment to family Poor behavioral monitoring Supportive, caring parents Large family size Family harmony Anti-social role models Secure and stable family Abuse and/or Neglect Small family size Marital discord in parents, divorce More than two years between siblings Harsh or inconsistent discipline style High level of family responsibility Family violence and disharmony Strong family norms and morality Low parental involvement in kids’ activities Economic security Long term parental unemployment Frequent contact with relatives Parental criminality, substance abuse, mental health disorder Access to mentors Critical, unsupportive partner Social connectedness and support Bullying, victimization, and peer rejection Multiple friendships Lack of social connectivity
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Adverse Childhood Experiences (ACE’s)
Joint study done by the CDC and Kaiser Permanente which demonstrated an association of adverse childhood experiences (ACEs) with health and social problems as an adult.
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Three Types of ACEs
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ACEs Increased Health Risks
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51 times more likely as a child or adolescent
ACEs have a strong, graded relationship to trauma based mental heath or addiction issues or suicide attempts during childhood/adolescent and adulthood ACE score of 7 or more: 51 times more likely as a child or adolescent 30 times more likely as an adult Nearly 2/3 (64%) of trauma based mental health or addiction issues, or suicide attempts among adults are attributable to ACEs and 80% during childhood/adolescence are attributed to ACEs Source:Dube et al, 2001
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MH/SUD PROTECTIVE FACTORS
MH/SUD RISK FACTORS MH/SUD PROTECTIVE FACTORS Community and Cultural Factors Socio-economic disadvantage Sense of connectedness to community Social or cultural discrimination Attachment to community networks Neighborhood violence and crime Participation in church or other community group Overcrowded housing conditions Strong cultural identity and ethnic pride Lack of recreational opportunities Access to support services Lack of support services Community cultural norms against violence Caring neighborhood
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MH/SUD PROTECTIVE FACTORS
MH/SUD RISK FACTORS MH/SUD PROTECTIVE FACTORS School Factors School Factors Poor attachment to school School achievement Bullying Sense of belonging at school Peer rejection Positive school climate Inadequate behavior management Pro-social peer group Deviant peer group High expectations School failure Required responsibility and service to others Frequent school transitions Opportunities for success Opportunities for recognition of achievement School norms against violence Child receives support from adults other than parents School provides clear rules and boundaries
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MENTAL HEALTH RISK FACTORS MENTAL HEALTH PROTECTIVE FACTORS
Societal Factors Societal Factors Prejudice Social inclusion policies Perceived discrimination Anti-discrimination laws Lack of cultural identify Education policies Stigma Gender-equity policies Societal norms of accepted behaviors Awareness raising campaigns Inadequate health, economic, and educational policies Responsible reporting in the media
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Significant overlap of risk and protective factors as related to social and MH/Addiction issues On average, nearly 75%!
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Different Forms of Violence
Trauma Based MH/SUD Child Maltreatment: physical, sexual, emotional, neglect Teen Dating Violence Sexual Violence Intimate Partner Violence Elder Abuse Peer Violence: youth violence, bullying, gang-related violence, fights CHILDHOOD ADOLESCENCE ADULTHOOD
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Individual Risk Factors
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Relationship Risk Factors
X
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Individual/Relationship Protective Factors
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Community Risk Factors
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Community Protective Factors
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Societal Risk Factors CM TDV IPV SV YV Bullying MH/SUD Elder Abuse
Norms supporting aggression* X Media Violence Societal income inequality Weak health, educational, economic, and social policies/laws Harmful gender norms* NOTE: CM (Child Maltreatment), TDV (Teen Dating Violence), IPV (Intimate Partner Violence), SV (Sexual Violence), YV (Youth Violence)
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Can we imagine: A generation without one new case of trauma-related mental or substance use disorder? A generation without a death by suicide? A generation without one person being jailed or living without a home because they have an addiction or mental illness? A generation without one youth being bullied or rejected because they are LGBT? A generation in which no one in recovery struggles to find a job?
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www.cdc.gov/violenceprevention/ pub/connecting_dots.html
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QUESTIONS???
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