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

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

4. BEHAVIORAL HEALTH IS ESSENTIAL TO HEALTH4
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

5. BEHAVIORAL HEALTH IMPACTS5
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)

6. PREMATURE DEATH AND DISABILITY6
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

7. 10 Leading Causes of Death, United States 2008, All Races, Both Sexes7
RANK
ALL AGES 1.
Heart Disease: ,828 2.
Malignant Neoplasms: ,469 3.
Chronic Low Respiratory Disease: ,090 4.
Cerebro-vascular : ,148 5.
Unintentional Injury: ,902 6.
Alzheimer's Disease: ,435 7.
Diabetes Mellitus: ,553 8.
Influenza & Pneumonia: ,284 9.
Nephritis: ,237
10.
Suicide: ,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

8. 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)

9. MISSED OPPORTUNITIES = LIVES LOST9
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…

10. DAILY DISASTER OF UNPREVENTED AND UNTREATED M/SUDs10
Any MI: million
39.2 % receiving treatment
SUD: million
11.2 % receiving treatment
Diabetes: million
84 % receiving treatment
Heart Disease: 81.1 million
74.6 % receiving screenings
Hypertension: 74.5 million
70.4% receiving treatment

11. CHRONIC DISEASES: GLOBAL IMPACT11
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

12. ECONOMIC IMPACT ON AMERICA12
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

13. IMPACT ON PHYSICAL HEALTH13
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

14. 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.

15. IMPACT OF TRAUMA Childhood trauma is extensive15
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

16. 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

17. TRAUMA & JUSTICE: Homelessness17
~ 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)

18. TRAUMA & JUSTICE: Jail Diversion18
> 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

19. IN AN ENVIRONMENT OF CHANGE19
EMERGING SCIENCE
Health Reform
State Budget Declines
Federal Domestic Spending

20. 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

21. 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

22. HEALTH REFORM: AFFORDABLE CARE ACT22
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

23. WHAT’S NEXT? Medicaid expansion & health exchanges – 1/1/1423
Medicaid expansion & health exchanges – 1/1/14
Simplified Medicaid eligibility
Enrollment
Essential health benefits (state choices)
More primary/behavioral health integration
Increasing parity

24. 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

25. TRAGEDIES Grand Rapids, MI Tucson, AZ 2011 – 8 Lost Asher Brown25
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
Lost
Red Lake Band of Chippewa, MN, 2005 – 10 Lost
Columbine High School, TX
Lost

26. FROM EVENTS TO ASSUMPTIONS26
Individual Blame
Misunderstanding
Prejudice
Discrimination
Moral judgment
Social exclusion

27. LEADING TO INSUFFICIENT RESPONSES27
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

28. 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

29. WHAT AMERICANS DON’T KNOW29
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

30. 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)

31. 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